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EVENT RELEASE FORM
I am a participant in the following promotional event: HEARTLAND STAR. The event is sponsored, in part, by Raycom Media, Inc. dba UPN The Beat.
In consideration for my participation in the event, I hereby agree to:
I certify that I have read the contest rules for the event and that I meet the eligibility requirements contained in such rules. I hereby certify that I am competent to contract in my own name in so far as the above is concerned. I have read the foregoing release, authorization and agreement before affixing my signature below and warrant that I fully understand the contents thereof.
(PRINT name) (Signature)
(Social Security Number)
(Street Address) (City/State/zip)
(Home Phone number) (Work Phone Number)
(Date of Birth) (Age)