This will allow use of your picture on Local T.V., presently Aurora Community Television, and Waubonsee Cable, known as FVTV.  Future local cable channels may be added.  Please complete and turn in, with a picure that cannot be returned, to my mail box if I am serving your school.  If you wish, I will take a picture, as I have with the ones that are on the show presently. 

I, (Print) __________________________________________________  do hereby consent to the use of my name, likeness, picture(s) and/or voice for use by ACTV, FVTV, and any other local cable channels that may be contracted, by Mr. Walter H. Duy for cable casting, direct exhibition, and subsidiary purposes in conjuction with the production of "Mr. Duy's Bully Buster Workshop".  Such use(s) will not be made with the purpose of selling or pormoting commercial products or services, endorsing political or elected candidates for public office, and/or appealing to prurient interest with obscene content.  I further hereby indemnify and hold harmless Walter H. Duy, the above named person's school and school distrilct, the City of Aurora, the Cilty's currnet cable, or any other cable station being used, franchise holder and/or their licensees, elected officials, and or personnel arising from the taping, editing and/or cable casting of the program referred to above.

Signed: ______________________________________________________________   Date: __________

Print School and District______________________________________________________________

If you do not work in a school being served by Mr. Duy, you may send this with your picture to Mr. Duy, P.O. Box 122, Sugar Grove, IL  60554