Milton Ulladulla Videography Club Inc Tony Mann Secretary 24 Coral Tree Lane LITTLE FOREST NSW 2538 Phone: (02) 4456 5050 Mobile: 0409 592 189 Email: tonymann@outlook.com.au CONSENT TO BE VIDEO RECORDED and/or AUDIO RECORDED This is to certify that I : NAME :   PLEASE PRINT ADRESS:   PLEASE PRINT PHONE:   EMAIL:   Hereby give permission to the members of Milton Ulladulla Videography Club Inc to video record images and related audio of me, within their video production of: I grant the Milton Ulladulla Videography Club Inc the right to make a visual recording and/or audio recording of my participation within the above named production and authorise the use of the recording in whole or part in any manner the Milton Ulladulla Videography Club Inc considers appropriate, including for promotional purposes, editing, synchronisation with visual images, adaptation for other publications (written or electronic) and re-publication. I herby give permission that my visual recording and/or audio recording of my participation may be used and shown within Contests and/or Film Festivals for public viewing within Australia. Including the Reel Escape Film Festival at Milton Theatre I agree to grant the Milton Ulladulla Videography Club Inc the above with no fee. SIGNED:   As named above SIGNED:   For and on behalf of Milton Ulladulla Videography Club Inc DATE:   DATE:   http://www.muvc.org.au