Adams Community Television (717)334-3000

P.O. Box 3505 fax (717)549-3640

Gettysburg, PA 17325

RELEASE

(Print Name, Address & Telephone Number)

acknowledge and agree for Adams Community Television to interview and/or use
my likeness or premise for broadcasting, distribution, or reproduction. I
understand that Adams Community Television is a nonprofit organization whose
mission is to serve the Adams County and surround counties.

By signing this release, I acknowledge and agree that the video and audio
portions of my interview/likeness are the exclusive property of Adams Community
Television who may, among other things, air, distribute, and/or reproduce my
interview/likeness premise for a fee, as Adams Community Television may deem
appropriate.

By signing this release, I release and hold harmless Adams Community

Television as to all legal issues including but not limited to copyright and property
rights as a result of my participation.

Adams Community Television Signature (Parent or Guardian if under 18) Participant Signature

Date Date

Adams Community Television Inc.

P.O. Box 3505 • Gettysburg, PA l~325
• "I'-334-3000 • \nn\:actv.org * uclvfaactv.org •