Televise Program

    Use this form to request program playback of completed tapes submitted or offered by community producers or sponsors. Complete one form for each program or series.

    Contact

    Program Title:

    Episode Title:

    Production Date (When the production was completed.):

    Produced By:

    Sponsoring Organization (if applicable):

    Program Description (This will likely be used in our program listings. You can pull diagonally down on the text box to make it larger, but we'll see everything you type regardless.) :

    Program Particulars

    Total Program Length (please try to be exact):
    Hrs Min Sec

    Is this program part of a series?

    If Yes, Part # of

    Does the program contain harsh language or adult themes?

    If Yes, is there disclaimer before the program?

    Tape format:

    Delivery:

    For electronic file:
    program_playback@midpenmedia.org Number of tapes in the program:

    If submitting physical media, do you want your media returned?

    TELVUE CONNECT OPTION

    Please distribute my program through Telvue Connect. The following Public Access TV Station(s) has/(have) agreed to accept my program via Connect :

    Or.....

    If you have a web site and / or a URL where your video can be viewed online, please include them:

    Special instructions regarding program or audio, etc.:

    Producer Agreement

    I am the producer or an agent of the producer of the program described on the opposite side of this form. I am submitting this program in the format described, for programming by the Media Center, a non-profit pubic benefit corporation. The program has no commercial content. I authorize Media Center, or any persons they may designate, to use the program, schedule for programming, cablecast, broadcast, transmit or distribute it by any channel, media or network Media Center uses for its programming purposes. I certify that I am the possessor, holder or authorized user of any copyright or copyright clearances for all copyrighted material or material which may be deemed to be the copyrighted property of another person or group which appears in the described program. I understand copyright material may consist of any music, graphic or fine art, performances, script, or written works from any source, trademark items or products used in the production of this program by myself or other party appearing in the program. I have approved the use of and authorize Media Center to use the likeness and voice of any person, living or dead, or of any minors which may appear in the program described. I am solely responsible for and hold Media Center harmless from any actions which may arise or result from the use of any of the abovementioned program materials. I understand that playback slots are allotted as the Media Center program schedule permits, with locally produced shows having higher priority. I understand that Media Center may pre-empt and reschedule the program. I will pick up the program tape at the Media Center facility after the cablecast date(s). I understand that if I do not retrieve the program within one year of this agreement, the Media Center has the right to recycle the program without contacting me. The program is supplied and submitted with the understanding that I, or any other person participating in the program, will receive no fee, compensation, royalties or remuneration from Media Center or others Media Center designated as users of the program. I certify that I am at least eighteen years of age. *Name and phone number of producer and sponsor will be public information.

    Producer Information

    Name *
    Address *

    Community Sponsor


    (A community sponsor is necessary if the producer does not live or work within the Media Center service area.)

    As a matter of public record, I wish to have the aforementioned program or program series cablecast on the Media Center Community Channel 27, 28, 30, or 75. I have been authorized by the program producer to submit this program to Media Center for playback. I have read and understand the Media Center playback policies listed above. I am a resident of Atherton, East Palo Alto, Menlo Park, Palo Alto or the Stanford University campus.

    Community Sponsor Information


    Name
    Address

    Image Code:
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