Scrammble Games Show(Dr. Wordman Show)

An Education Project Sponsored by Concerned Community Organizations

PO Box 944, Yorktown Heights, New York 10598

Tel 914-248-6770 Fax 914-248-6429 email scrammble@scramble.us

Website http://www.scrammble.us

Request/Release Form for Video Recording & Broadcasting

Players Names & Addresses
Email and Phone Contact
Event Date and Location
Sponsor Name If Any
Players School Names & Addresses If Any
Guardian Signature for given permission to video Recording & Broadcasting	Guardian Signature: Player Signature (Optional):
Date of Event	____________________, Year _____
Release Form Received BY Name	Committee Member of Scrammble Tournament & Workshop ___________
Consent to Press Interview & Report	Applies to recording & broadcasting event, Guardian Initial ___________

Thank you for participating in the ‘Community Education- Scrammble Tournament & Scrammble Games Show’. The game show is broadcast through public TV/Cable Channels, Schedules see www.scrammble.us

* Scrammble Tournament is a community education project to provide a fun event that stimulates good learning habit for children and family in communities

** Scrammble Games Show (nicknamed Dr. Wordman Show, no relation to Mr. Letterman Show) will be held at Cablevision Studios, details see www.scrammble.us CC: Cablevision