Heartland Star Registration Form

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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:

  • Release any and all claims, demands and causes of action of any nature whatsoever which I have or may hereafter have against WQWQ-TV, KFVS-TV, their parent companies, subsidiaries, affiliates, officers, directors, employees, and agents and the other sponsors of the event (collectively, “Sponsors”) arising out of or in connection with said event, including, without limitation, participation in and/or other related activities of the event.
  • Grant to Sponsors the right to use my name, likeness, portrait, recorded voice and/or biographical material, in order to advertise, promote and publicize either of them.
  • Waive the right to inspect or approve the finished videotape, sound track, advertising copy or printed matter that may be used in conjunction therewith or to any eventual use that it might by applied.
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.
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 (PRINT name)                                (Signature)
(Social Security Number)
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(Street Address)                               (City/State/zip)
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(Home Phone number)                     (Work Phone Number)
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(Date of Birth)                                  (Age)