Experience the Prairie Waters Region
Registration Form
Video contest with cash prizes!
Due date for submission: June 17, 2009
Title of Video:
Location(s) of Video:
Video should be of a location, experience, event or person in the four county region:
Chippewa County including cities of Milan, Watson, Montevideo, Clara City, Maynard
Lac qui Parle County including cities of Bellingham, Nassau, Marietta, Madison, Dawson, Boyd
Swift County including cities of Clontarf, Benson, DeGraff, Murdock, Kerkoven, Holloway, Appleton
Yellow Medicine County including cities of Clarkfield, Granite Falls, Hazel Run, Hanley Falls, Wood Lake, Echo, St. Leo, Porter, and Canby
Participant(s) name:______________________________________________________________
Contact Person: __________________________________________________________________
Phone Number: __________________________________________________
Email Address: ___________________________________________________
Please submit one form with each video entry.
By mail:
Western MN Prairie Waters
323 W. Schlieman Ave
Appleton, MN 56208
By email:
prairiewaterstourism@gmail.com
By fax:
320-289-1983
Actor Release Form
Authorization to Reproduce Physical Likeness and/or Voice
I hereby irrevocably grant Prairie Waters to (herein "Producer") and any parent, subsidiary and affiliated corporations and their respective successors, assigns, licensees, employees and agents, the right in perpetuity throughout the universe, and in all now known and hereafter existing media, and in any language, to use my (child’s) name (including any fictitious names heretofore or hereafter used by me), physical likeness and/or voice in and in connection with the production, exhibition, exploitation, merchandising, advertising and promotion of the production tentatively entitled _____________________________________ (the "Production").
I agree that the foregoing grant includes the right to use my (child’s) physical likeness in any form, including, without limitation, a photograph, picture, artistic rendering, silhouette or other reproduction by photograph, film, tape, or otherwise.
I represent to the best of my knowledge that the consent of no other persons, firm corporation or labor organization is required to enable Producer to use my (child’s) name, likeness and/or voice as described herein and that such use will not violate the rights of any third parties.
I acknowledge that nothing herein requires Producer to use my (child’s) likeness and/or voice as described herein or in connection with the Production.
The rights granted herein include the right to use the Production or excerpts or stills from the Production (include excerpts or stills containing my (child’s) likeness and/or voice) in any other motion picture, publication, recording, or other medium and includes the right to edit, delete, and/or juxtapose (with any other part of the Production), any part of the Production in which I/my child appear(s), and/or change the sequence of events in the Production.
All rights, title and interest in and to the results and proceeds of the services and performances rendered by me/my child in connection with the production of the Picture or any portion therefore shall, from its inception, be the sole property of Producer, free from any claim whatsoever by me/my child or any other person.
This agreement contains the full and complete understanding between the parties and supersedes all prior agreements and understandings pertaining hereto and cannot be modified except by writing signed by each party.
I hereby certify and represent that I am of legal age and have every right to contract in my own name in connection with this Release, and that I have read the foregoing and fully understand the meaning and effect thereof, and intending to be legally bound I have signed this Authorization this __________ day of _________________________ , 2009.
Signature:
(Signature of parent or guardian if actor is under the age of 18)
Print Name:
Name of Actor:
Address: ___________________________________________________
