Conor Fitzpatrick

RELEASE FORM

WORKING TITLE: HOPE

Brief Outline:
Documentary raising awareness and help for the charity Hope For Paediatric Epilepsy.

I/We agree to participate in the production of the above mentioned item and or give
permission for our child to be included, the nature and composition of which has been fully
explained to me/us and hereby give consents for the filming of and/or recording and/or
broadcasting of my/our acts, material and performances to Clarendon Sixth Form College
or their affiliates.

I/We acknowledge this includes, without limitation the sole and exclusive rights for
Clarendon Sixth Form College or their affiliates to tape, record, cut, edit or otherwise fix
and to cablecast, duplicate or distribute any filming, recording or broadcasting or any part
thereof in which my/our acts, materials, expertise or performance are included, in any form
and at any time in/to all countries of the world and to use my/our name or likeness in/or
relation to the same.

Signed:
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Print name:
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Contact address:
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Telephone No
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Email:
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*Your details may be included in CLARENDON SIXTH FORM COLLEGE website. Please
indicate if you give your approval for your details to be used in this way.

YES/NO

Details for Website:

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Please return to:

Address: Camp Street, Ashton Under-Lyne OL6 6DF
Tel: 0161 908 6800
Email: conormediaa@gmail.com
Website: www.clarendonsixth.com