CONSENT AND RELEASE FORM

To: _ _ _ _ _ _ _ _ _ _ _ _ (name and address of production company)

I understand that you desire to use all or parts of the events of my life in order to have one or
more screenplays written and to produce, distribute, exhibit and exploit one or more motion
pictures of any length in any and all media now known or hereafter devised and sound
recordings in any and all media now known or hereafter devised, and to publish one or more
publications of any kind, based upon, derived from or suggested by all or parts of the events of
my life. I have agreed to grant you certain rights in that connection. This Consent and Release
confirms our agreement as fo!lows:

1. CONSIDERATION: GRANT OF RIGHTS: In consideration of the payment tome of (amount of

payment) ($(amount)) (payable upon your receipt of this Consent and Release signed by me) or
(payable on (specify date)) with full knowledge I hereby grant you, perpetually and irrevocably,
the unconditional and exclusive right throughout the universe to use, simulate and portray my
name, likeness, voice, personality, personal identification and personal experiences, incidents,
situations and events which heretofore occurred or hereafter occur (in whole or in part) based
upon or taken from my life or otherwise in and in connection with motion pictures, sound
recordings, publications and any and all other media of any nature whatsoever, whether now
known or hereafter devised. Without limiting the generality.of the foregoing, it is understood and
agreed that said exclusive right includes theatrical, television, dramatic stage, radio, sound
recording, music, publishing, commercial tie-up, merchandising, advertising and publicity rights
in all media of every nature whatsoever whether now known or hereafter devised. I reserve no
rights with respect to such uses. (All rights are hereinafter referred to as the "Granted Rights.") It
is further understood and agreed that the Granted Rights may be used in any manner and by
any means, whether now known or unknown, and either factually or with such fictionalization,
portrayal, impersonation, simulation and/or imitation or other modification as you, your
successors and assigns, determine in your sole discretion. I further acknowledge that I am to
receive no further payment with respect to any matter referred to herein. Any or all of the
Granted Rights shall be freely assignable by you. .

2. RELEASE : I agree hereby to release and discharge you, your employees, agents, licensees,
successors and assigns from any and all claims, demands or causes of action that I may now
have or may hereafter have for libel, defamation, invasion of privacy or right of publicity,
infringement of copyright or violation of any other right arising out of or relating. to any utilization
of the Granted Rights or based upon any failure or omission to make use thereof.

3. NAME--PSEUDONYM: You have informed me and I agree that in exercising the Granted
Rights, you, if you so elect, may refrain from using my real name and may use a pseudonym
which will be dissimilar to my real name, however, such agreement does not preclude you from
the use of my real name should you in your sole discretion elect and that in connection therewith
I shall have no claim arising out of the so-called right of privacy and/or right of publicity.

or

We agree that in exercising the Granted Rights, you will refrain from using my real name and
instead will use a pseudonym which will be dissimilar to my real name.

4. FURTHER DOCUMENTS: I agree to execute such further documents and instruments as you
may reasonably request in order to effectuate the terms and intentions of this Consent and
Release, and in the event I fail or am unable to execute any such documents or instruments,
[after receipt of a written request therefore from you,] I hereby appoint you as my irrevocable
attorney in fact to execute any such documents or instruments, provided that said documents
and instruments shall not be inconsistent with the terms and conditions of this Consent and
Release. Your rights under this Clause 4 constitute a power coupled with an interest and are
irrevocable.

5. REMEDIES: No breach of this Consent and Release shall entitle me to terminate or rescind
the rights granted to you herein, and I hereby waive the right, in the event of any such breach, to
equitable relief or to enjoin , restrain or interfere with the production, distribution, exploitation,
exhibition or use of any of the Granted Rights, it being my understanding that my sole remedy
shall be the right to recover damages with respect to any such breach.

6. PUBLIC DOMAIN MATERIAL: Nothing in this Consent and Release shall ever be construed to
restrict, diminish or impair the rights of either you or me to utilize freely, in any work or media,
any story, idea, plot, theme, sequence, scene, episOde, incident, name, characterization or
dialogue which may be in the public domain from whatever source derived.

7. ENTIRE UNDERSTANDING: This Consent and Release expresses the entire understanding
between you and me, and I agree that no oral understandings have been made with regard
thereto. This Consent and Release may be amended only by written instrument signed by you
and me. I acknowledge that in granting the Granted Rights I have not been induced to do so by
any representations or assurances, whether written or oral, by you or your representatives
relative to the manner in which the Granted Rights may b~ exercised and I agree that you are
under no obligation to exercise any of the Granted Rights and agree I have not received any
promises or inducements other than as herein set forth. The provisions hereof shall be binding
upon me and my heirs, executors, administrators and successors. I acknowledge that you have
explained to me that this Consent and Release has been prepared by your attorney and that you
have recommended to me that I consult with my attorney in connection with this Consent and
Release, and that I have either consulted with an attorney of my own choosing or have
voluntarily chosen not to do so. [This Consent and Release shall be construed in accordance
with the laws of the State of California applicable to agreements which are fully signed and
performed within the State of California and I hereby waive any rights I may have, known or
unknown, pursuant to Section 1542 of the California Civil Code which provides:
" A general release does not extend to claims which the creditor does not know or suspect to
exist in his favor at the time of executing the release, which if known by him must have materially
affected his settlement with the debtor.'1

In witness hereof and in full understanding of the foregoing, I have signed this Consent and
Release on this (date).

(Signature)

(Name, please print)

(Address, please print)

AGREED:

(Name of Production Company)

By _ _ _ _ _ __
Its _ _ _ _ _ __

[An Acknowledgement must be appended to this Agreement.]