Music Video Minor Extra Permission Slip

Production Title:

Production Date(s):

Location:

Minor's Full Name:

Minor's Date of Birth:

Parent/Guardian Name:

Relationship to Minor:

Contact Phone:

Contact Email:

Address:

I give my consent for the above-named minor to appear as an extra in the referenced music video production. I understand that their image and likeness may appear in the final production and related promotional materials.

Notes (optional):