Media Disclosure Form - 2018


Station ID:    

Participant Name:  

Parent/Legal Guardian Name:  



City, State:  



In consideration for allowing me to participate in the  programming of Family Radio (as defined below), I hereby agree to this Publicity Waiver and Release (this “Release”) and authorize Family Stations Inc., a California corporation, its affiliates, successors and assigns, and the employees, agents and representatives of each (collectively, “Family Radio”) to use my likeness, name, signature, voice and other personal characteristics and private information (“Likeness”) for any purpose including, but not limited to, fundraising for Family Radio, or advertising, publicizing, or marketing its programs, without further consent from, or royalty, payment or other compensation to, me.

I hereby irrevocably authorize Family Radio and its licensees to edit, alter, copy, exhibit, publish or broadcast my Likeness and any materials created by or on behalf of Family Radio that incorporate my Likeness (“Materials”) on a perpetual basis throughout the world and at any time by means of any media including, but not limited to, print, video presentations, television, radio and satellite transmissions or rebroadcasts, news bulletins, mailers, billboards or signs, brochures, website placements, Social Media postings, podcasts or other digital delivery or publications. I hereby irrevocably transfer and assign to Family Radio my entire right, title and interest, if any, in and to the Materials. I understand that I have no right to inspect or approve the Materials before they are used by Family Radio or its licensees. I also understand that Family Radio and its licensees have no liability to me for any editing or alteration of the Materials. To the fullest extent permitted by applicable law, I hereby: (i) irrevocably waive all legal and equitable rights relating to all liabilities, claims, demands, actions, suits, damages and expenses, now known or hereafter known in any jurisdiction throughout the world (each, a “Claim”) arising directly or indirectly from Family Radio’s exercise of its rights under this Release; (ii) covenant not to make or bring any such Claim against Family Radio or its licensees; and (iii) forever release and discharge Family Radio and its licensees from liability under such Claims. I understand that I may later discover Claims or facts that may be different than or in addition to those which I now know or believe to exist with regards to the subject matter of this Release and which, if known at the time of my signing this Release, may have materially affected this Release or my decision to enter into it. Nevertheless, I hereby waive any right or Claim that might arise as a result of such different or additional Claims or facts. I have been made aware of and understand the provisions of California Civil Code Section 1542 and hereby expressly waive any and all rights, benefits and protections of the statute, which provides:

A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR. This Release supersedes all prior and contemporaneous understandings, agreements, representations and warranties with respect to the subject matter contained herein. If any term or provision of this Release is invalid, illegal or unenforceable in any jurisdiction, such invalidity, illegality or unenforceability shall not affect any other term or provision of this Release or invalidate or render unenforceable such term or provision in any other jurisdiction. This Release is binding on and shall inure to the benefit of the parties hereto and their respective successors and assigns. All matters arising out of or relating to this Release shall be governed by and construed in accordance with the internal laws of the State of California without giving effect to any choice or conflict of law provision and you agree to exclusive personal jurisdiction and venue in the state and federal courts of the United States located in the State of California, City of Sacramento. I hereby acknowledge that I have read this release and fully understand the content, meaning and impact of its terms. I hereby represent to Family Radio: (i) that I am the participant named below, that I am 18 years of age and competent to contract in my own name; or (ii) if the participant named below is under 18 years of age, that I am the parent or legal guardian of the participant named below, that I have the legal right to consent to and, by signing below, hereby do give my consent to the terms and conditions of this Release on behalf of myself and the participant. If this Release is signed electronically, I hereby agree that my electronic signature below is intended to authenticate this writing and to have the same force and effect as a manual signature. 

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Signature Certificate
Document name: Media Disclosure Form - 2018
Unique Document ID: f85a4607a48b8406502fbe2e213d13b0a50a97f8
Timestamp Audit
February 12, 2018 3:00 pm EDTMedia Disclosure Form - 2018 Uploaded by Jennifer Burkhiser - IP