Group Release Form
for Broadcast, DVD, Web
Digital Technology and Culture
Washington State University Vancouver
14204 NE Salmon Creek Ave.
Vancouver, WA 98686
Program Director - Dene Grigar
360-546-9487
In connection with my appearance in the video program titled
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I authorize Washington State University students and/or staff to record on videotape, film,
audiotape, or otherwise, my name, likeness, voice and performance. I also authorize
Washington Sate University to use such recordings for non-commercial and educational
purposes. These recordings may be distributed/broadcast on television, DVD, and/or the
Internet. Washington Sate University may also use my name, likeness, voice, and
biography for publicizing and promoting such distribution. I understand that I will not be
paid for my appearance in these recordings.
Printed Name: Signature: Date:
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