Media Consent and Release Form

I understand I will not be paid or compensated, now or in the future for my participation in this show. I hereby give my consent to Savvy Cleaner and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet).

This consent includes, but is not limited to:

1. YES (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;

2. YES (b) Permission to use my name; and

3. YES (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.

This consent is given in perpetuity and does not require prior approval by me.

YES. I certify that I am 18 years of age or older and have the authority to authorize the use of my participation.

By signing this consent form with my name and digital signature I agree to the above terms.