Participant Full Name(Required)Date(Required) MM slash DD slash YYYY Consent(Required) I hereby irrevocably grant and assign to Springfield Little Theatre the right to use my “Likeness,” in any media in connection with or for the promotion of this Program and/or SLT.VALID FOR ANY PRODUCTION, PERFORMANCE or EVENT from JULY 1, 2025– JUNE 30, 2026. In exchange for the opportunity (but not the guaranty) to participate or appear in the above-identified Program, I hereby irrevocably grant and assign to Springfield Little Theatre (SLT) the right to use my “Likeness” (i.e. my name, my biography, my physical likeness and/or my voice), in any media in connection with or for the promotion of this Program and/or SLT. This grant and assignment includes, but not limited to, the right of SLT to capture, record, use, reproduce, exhibit, edit, project, display, copyright, publish, release, sell and resell my Likeness (in whole or in part) through photographic images, moving pictures, videotaped images, sound recordings and any other types of media, from and after today’s date, for any lawful program, production or use authorized by SLT, including but not limited to educational, programming, publicity and promotional purposes. I agree that SLT may use my Likeness for any period of time that SLT, in its sole discretion, finds reasonably necessary; and that I shall not receive any compensation for my participation in the above-identified Program or for SLT’s use of my Likeness. I confirm that all materials I may furnish for this Program are either my own or that I am authorized to use them and that SLT has no obligation to me or to any third party in connection with my use of such materials. I agree that my participation in the Program confers upon me no rights to the use or ownership of or copyright interest in my Likeness as captured or used by or for SLT in connection with the Program. I release SLT, its employees, agents and assigns from all liability that may arise from any claims by me and/or any third parties in connection with my participation in the Program or use of my Likeness. I understand that SLT has no obligation to broadcast or use the above-identified Program.Participant Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Participant The participant is under 18 years of age. Parent/ Legal Guardian InformationIf the participant is under the age of 18, parent/ legal guardian please complete the below information.Parent/ Legal Guardian Name(Required)I am the parent/ legal guardian of the above-named minor and I endorse the above statement in his/her behalf.Parent/ Legal Gaurdian Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Δ
