AUTHORIZATION FOR CHANNEL 17

I, the undersigned, hereby give my permission for the following to be Videotaped and/or shown on the Town of Trumbull local access Channel 17. I further understand that no fees will be charged for either video taping or airing on television.

_____________________________
Event/Activity

_____________________________
Date of Event/Activity

_____________________________
Print Name

_____________________________
Signature

_____________________________
Phone number

_____________________________
Date

RETURN TO CHANNEL 17 ADMINISTRATION

7/05