Heritage Theatre Webathon Submission Form
Primary Contact Information:
Phone Number:
Phone 2:
About the Performance:
Who Is in This Performance:
About the Performance: (Description, Title of Piece, Credits, Etc.)
Fun Fact About the Performers or the Performance:
(If all participants are covered under one parent or guardian, only one form will need to be filled out.)
Are any of the participants under the age of 18? __________
If any of the participants are under the age of 18, the primary contact listed above must be legal guardian to those appearing in the
performance and must sign below on behalf of those performing in the submitted video.
Video Release:
I hereby grant permission to The Heritage Theatre the rights of my image, in video or still, and the likeness and sound of my
voice as recorded on audio or video without payment or any other consideration. All images, audio, and video will be used for
the purposes of fund raising and marketing by The Heritage Theatre.
By signing below, I understand submitted material will be electronically displayed via the internet or in a public setting. There is
no time limit of the validity of this release, nor is there any geographic limitation on where these materials may be distributed.
I understand I will not be consulted about the use of the submitted material.
By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to be bound
thereby. I hereby release any and all claims against Heritage Theatre utilizing this material.
Signing Below As: ____ Parent/Guardian or ____Person Performing
_____________________________________________ ______________________________
Signed Date
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