Raymond Community Television Raymond, NH

4 Epping St. Raymond, NH 03077 603-895-6405 www.raymondtv.org

PARENTAL RELEASE FORM FOR MINORS WITH ACCESS PRIVELEGES
Form RCTV-5

By signing below, I hereby acknowledge that I have read and fully understand the rules described in the Raymond Community Television PEG Access Policies, and agree to take responsibility for the actions and content of programming produced by my child. I also understand that I am financially responsible for any equipment or facilities used by my child.

Full Name

Child’s Name

Address

Phone

(to be made available to the general public upon request)

E-Mail

Parent’s Signature ___________________________________ Date___________