A T.V. series on bullying using the local Comcast T.V. cable channel 10  in Aurora and channel 17 in the Oswego - Plano area is being produced.  We would like to identify those students who are against bullying and would like to have their pictures on T.V.  Please complete below if you wish to have your child included.

Print Student Name __________________________________________

School _____________________________________     District ___________

Teacher's Name ________________________________________

Enclose a photo of your child that cannot be returned.  Write your child's name and school on the reverse side.

I, (print) ________________________________________________ being the parent or legal guradian of the above named minor, consent to the use of said minor's image, name, likeness, picture(s), and/or voice for use by ACTV and/or FVTV by Mr. Walter H. Duy for cable casting, direct exhibition, and subsidiary purposes in conjunction with the production of: "Mr. Duy's Bully Buster Workshop".  Such use(s) will not be made with the purpose of endorsing political or elected candidates for public office, and/or appealing to the prurient interest with obscene content.  No financial gain is to be requested from the above. I further hereby indemnify and hold harmless Walter H. Duy, the above named child's school district, the City of Aurora or other cities in the above named cable companies viewing area, the Cities current cable franchise holder and/or their licensees from any and all claims or actions against prior mentioned and said organizations's licensees, elected officials, and or personnel arising from the taping, editing and/or cable casting of the program referred to above.

Signed: ________________________________________________

Date: ____________

Print address __________________________________

                         ___________________________________ 

Complete form and send to Mr. Duy; P.O. Box 122; Sugar Grove, Il 60554.  Picture cannot be returned.