APPENDIX 5

Consent of Parent or Legal Guardian

I, ______________________, hereby give permission for
      (Parent/Legal Guardian)

________________________ my __________________________, ("minor")
  (Name of minor)                             (Insert "son", "daughter" or "ward")

to participate in the production of _________________ and
                                                          (Program Title)

accept financial responsibility for the actions of said minor during the production of this Public Access program. In case of emergency, I understand that a reasonable effort will be made to contact me, the minor’s Parent/Legal Guardian.

In the event that I cannot be reached, please contact:

______________________ at ______________________.
          (Name of Adult)                    (Phone Number)

___________________________________ ________________________
(Parent/Legal Guardian - Signature) (Witness - Signature)

___________________________________ ________________________
(Address) (Witness- Print Name)

___________________________________
(Phone #)

Dated:____________________________