Toastmasters International

Audio/Video Taping Release Form

(if applicable)
Section I - Agreement:
Date of Contract Execution:_____________________________________________________________________
This agreement is between ___________________________________________________________________ and
(Speakers Name)

______________________________________________________________________to deliver a presentation for

(District Governor or event organizers name)

___________________________________________________________________________________________as
follows in Section II, Program Information.
Section II - Program Information:
Presentation Title:_____________________________________________________________________________
Event Date:__________________________________________________________________________________
Event Name:_________________________________________________________________________________
Location of Event:_____________________________________________________________________________
Session Start Time:______________________ Session Finish Time:___________________ Breaks:___________
On-site Contact:_______________________________________________________________________________
Please initial accordingly below:

Initial _________ I grant permission to __________________________________ to Audio and/or Video record my presentation
given at the above event.

Initial _________ I grant permission to __________________________________ to use the Audio and/or Video recording of my
presentation given at the above event for educational purposes only.

Initial _________
the event.

I request a complimentary copy of the Audio and/or Video recording taken at the above event within 30 days of

Initial _________

I do not grant permission to Audio and/or Video record my presentation at the above event.

Accepted and Approved:

Speaker

District Governor or event organizer

By: ___________________________________________
(Signature)

By: ____________________________________________
(Signature)

___________________________________________
(Print Name)

____________________________________________
(Print Name)

Date: __________________________________________

Date: ___________________________________________