Form Center

2. Program Name
3. Date
   Date
5. I, the undersigned, am 18 years of age or older and agree to appear without payment as a guest on the above named Riverside TV program. The Village of Riverside and its Cable Commission representatives may use and reuse forever, license others to use my name, voice, pictures, images of works, and/or statements made by me on the subject program for any use, including promotional use for the program, and I shall not be entitled to any compensation. Said Village and its Cable Commission representatives may edit my appearance as they see fit, and I understand that there is no obligation to use my appearance. The authority given herein is based upon the Village's agreement not to use my name or picture so as to amount to a direct endorsement by me of any product or service.
   
   I hereby indemnify the Village of Riverside, its officers, employees, volunteer commissioners, agents, representatives, and/or licensees respecting any claim arising out of my acts or statements made by me on the program, and I hereby release said Village and its agents, representatives, and or licensees and agree to hold them, and any of them, harmless from any loss or claims arising out of my appearance and participation in the program.
   
   I have carefully read the foregoing and have indicated my understanding and agreement by signing below. (In the case of persons under 18 years of age, a parent or guardian must sign this form.)
7. Name
8. Address
10. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
12. Electronic Signature
14. Electronic Signature of Witness or Representative of Village

    1. I agree.
16. Electronic Signature
Leave This Blank:


18. Submit

* indicates a required field