Carlin Chronicles Fishing Picture Contest - Release Form

By Matt Dooley
Production Coordinator
Published: May 28, 2007

Click
here to submit your photos

RELEASE

I (for myself or on behalf of the minor child identified below) hereby grant
Media General Operations, Inc., d/b/a WSLS-TV, the worldwide, perpetual right
and license to publish and broadcast in any medium (whether now known or hereafter
devised) the materials, name, likeness, voice, and personal information regarding
me (or regarding the minor child identified below) for any purpose, including
but not limited to advertising, promotional purposes, or purposes of trade,
specifically including but not limited to, the right to publish and broadcast
the videotaped image of my presence during the awarding of a prize during the
WSLS-TV 5TH ANNUAL CARLIN CHRONICLES FISHING PICTURE CONTEST. .

If signing on behalf of a minor child (under the age of 18), indicate the child’s
name, age and relationship to you in the space provided below:

Name: _____________________

Relationship: ________________________

Age: ___________

I HAVE READ THIS DOCUMENT AND UNDERSTAND IT FULLY.

________________________________

Signature Date

________________________________

Print Name

Return this form to:Carlin Chronicles Fishing Photo Contest c/o WSLS-TV, P.O.
Box 10, Roanoke, VA 24022. Or you can fax it to 540-343-2059