I
Appearance Release Form
Adult and Youth

Event/Program:*

Location:*

Event/Program Date(s): (if more than 1 date, separate with a comma)*

I have participated as indicated on the above Program. In consideration of my participation in the Program, and without further consideration from the City of Surrey, its employees, or representatives, I hereby grant permission to the City of Surrey, to utilize my likeness and biographical material about me in connection with the program for publication in brochures, websites and other promotional materials created by or on behalf of the City of Surrey. The purpose of the promotional materials is to promote the diverse businesses, residents and cultural aspects of the City of Surrey. I agree that the recording may be used in conjunction with any other material, as the City of Surrey may in its sole discretion determine.

I expressly release the City of Surrey, affiliates, employees, and representatives from and against any and all claims, demands, or causes of action which I may have for invasion of privacy, defamation, infringement of copyright or any other cause of action arising out of distribution, broadcast or exhibition of my likeness. This release shall be governed by the laws of British Columbia. The courts of British Columbia shall have exclusive jurisdiction in the event of any dispute under this release.

This release form is for an Adult or Youth (youth being aged 12 to 18 years old).

First Name:*

Last Name:*

Phone Number:*

Email:*

Address and City:*

Postal Code:

Signature:*

Signing Date:

The City of Surrey is collecting personal information under Section 26 (c) of the Freedom of Information and Protection of Privacy ActI consent to my information being used and disclosed as described above. For questions regarding the collection, use and disclosure of your information please contact the Manager of Marketing and Communications, 13450 104 Avenue Surrey, BC V3T 1V8 | Tel: 604-591-4011  | Web Privacy Code