Start Date:

Participant Release Form

19/10/16
Participants Name:
End Date:
Participants Contact
Details: 1/2/17

Production Name: Killhouse

Producers Name: Olivia Mungham-Gray
Producer Contact Details: Mob: 07895674332

Email: O.k.munghamg98@outlook.com

Emergency Contact Name of Contact: Name of 2nd Contact:

Details:
Mob:

Tel: Mob:

Name of Doctor: Tel:

Name of Surgery:

Mob:

Tel: {Optional}

Production and Filming City College Norwich

Locations:
Chappelfield Gardens

The Forum

The Castle Museum

The Royal Arcade

North Park Avenue

Various Roads And Locations Between North Park

Avenue And The City Centre

Team Members / Artists James Conner

/ Individuals Involved:
Olivia Mungham-Gray
Name of Risk Assessor: Olivia Mungham-Gray

Outline of Risk The purpose of this risk assessment was to highlight

Assessment: all of the possible risks that the individuals involved
could face at the varying locations while they are
filming the music video Killhouse. Signing below will
confirm that the individuals involved have read the
risk assessment, are aware of all of the risks, know
how to avoid said risks and are accepting full liability
if anything were to go wrong during the filming of
the music video. If anything that has been said or
shown is unclear then do not sign as you will still be
held accountable for anything that does go wrong.
 Participant Release Form

Please circle YES is you are either 16 Participants Signature:

or over the age of sixteen and NO if
Date Completed:
not:

YES NO

If the participant is under the age of Parent/legal guardians

16 then this is where you as a Signature:
parent/legal guardian are giving your
Date Completed:
child permission to partake in the
production and filming of this music
video. Please circle YES to say that
you have read the risk assessment
and agree to give your child
permission or circle NO if you do not
give permission:

YES NO

Risk Assessors
Signature:
Date Completed:

Producers Signature:

Date Completed: