COMBINATION APPEARANCE/MATERIALS PERMISSION AND RELEASE - MINOR

LICENSED MATERIALS (describe briefly):

WGBH  
One  Guest  Street  
Boston,  MA  
02135   For consideration that I acknowledge, I grant WGBH the rights to:
617-­‐300-­‐3848  tel  
617-­‐300-­‐1040  fax   (a) make any type of photograph or recording of me (the “Recordings”);
wgbh.org  
  (b) use the Recordings and the Licensed Materials, in whole or in part, with or without my
Education  
 
name and biographical details, in connection with any WGBH projects, other projects, and their
  related materials (collectively, the “Projects”) including to package, advertise and promote the
Projects, WGBH, its distributors and/or funders, including PBS; and

(c) exhibit, distribute, market, advertise, promote, license and/or sell the Recordings and
the Projects, in whole or in part, and authorize others to do so, in all forms of media now or
subsequently known or developed, throughout the world in perpetuity. Uses may include
uploading to websites, which by their terms of use allow third parties to download and possibly re-
use the Projects, in whole or in part, for other purposes.

I represent that I am authorized to grant the rights and permissions referred to above either because
I own the Licensed Materials or otherwise have the rights to give WGBH access to them for the
purposes stated above, and that my doing so will not violate anyone else’s rights.

I acknowledge that WGBH or its designees shall own the copyright in the Recordings and the
Projects, and that WGBH is not obligated to use the Recordings or the Licensed Materials.

I release WGBH and its designees from any claims that I have or may have relating to the
Recordings and the Projects.

Signature of Minor: Age:

Please also print your name here:

Date:

By signing this release I represent that I am the custodial parent or legal guardian of the minor
named above and agree that he/she is to be bound by the terms of the release.

Signature of Parent or Legal Guardian:

Please also print parent’s or legal guardian’s name here:

Address:

Email address (optional):

Date: Tel. (h) (o)

WGBH Internal Reference (initial use):
WGBH Minor Appearance/Materials Release 7/18/2011