Toastmasters International Audio/Video Taping Release Form (if applicable)

Section I - Agreement: Date of Contract Execution:_____________________________________________________________________ This agreement is between ___________________________________________________________________ and (Speakers Name) ______________________________________________________________________to deliver a presentation for (District Governor or event organizers name) ___________________________________________________________________________________________as follows in Section II, Program Information. Section II - Program Information: Presentation Title:_____________________________________________________________________________ Event Date:__________________________________________________________________________________ Event Name:_________________________________________________________________________________ Location of Event:_____________________________________________________________________________ Session Start Time:______________________ Session Finish Time:___________________ Breaks:___________ On-site Contact:_______________________________________________________________________________ Please initial accordingly below:

Initial _________ I grant permission to __________________________________ to Audio and/or Video record my presentation given at the above event.

Initial _________ I grant permission to __________________________________ to use the Audio and/or Video recording of my presentation given at the above event for educational purposes only.

Initial _________ I request a complimentary copy of the Audio and/or Video recording taken at the above event within 30 days of the event.

Initial _________ I do not grant permission to Audio and/or Video record my presentation at the above event. Accepted and Approved: Speaker District Governor or event organizer By: ___________________________________________ By: ____________________________________________ (Signature) (Signature) ___________________________________________ ____________________________________________ (Print Name) (Print Name) Date: __________________________________________ Date: ___________________________________________