Performer's Video Release Form

A seperate copy of this form to be completed by each performer

I hereby acknowledge my participation in the submitted video

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Title of Program

I hereby authorize you to use my name and likeness as displayed within the program and grant all rights to said production owner to use such recordings, in whole or in part for submission to the 'Circles of Light' compilation video as distributed by Home of Poi Ltd.

You may also use my name, likeness, and/or biography for publicity and promotion as deemed necessary.

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Produced by

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Signature of performer

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(Please print performer's full name here)

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Your name to appear in the credits

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Address


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City, State, Country, Zip

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Telephone

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Fax

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Email

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Date

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