Permission and Release

Activity: REAL LIFE. REAL TALK.® Interview

Location: __Casa Latina Family Education Center

________________________________________________________________

Date: March 19, 2009______________________________

I, _____Matilda Bonilla____________________________________, hereby agree to participate in and be possibly

videotaped, recorded, and/or photographed at/during the Activity described above. For good and valuable
consideration:

• I agree that Real Life. Real Talk. and its Partners and any licensees or assignees (collectively “Real Life. Real
Talk.”) shall own the copyright to any pictures, video, or audio taken of me, or any statements of mine that are
transcribed. This means that Real Life. Real Talk. will have the right in perpetuity to use and/or provide to other
national media outlets my name; likeness; photographic, video and audio images and statements made by me
(quotes), and to display, publish, edit, use excerpts, and/or broadcast the same. I understand I will not receive any
compensation or royalty. The Partners of Real Life. Real Talk., which may change from time to time, are listed on
the web site www.realliferealtalk.org.

• I specifically release and hold harmless Real Life. Real Talk. from any and all liability to me and/or my property,
arising out of my participation in the Program. This includes, but is not limited to, any claims of defamation,
privacy or publicity, or claims of alleged misrepresentation of me, my character, or my statements.

I do not have any other obligations or conflicts that would prevent me from agreeing to this Permission and Release.

I certify that I am 18 years of age or older or that I am under 18 years of age and my parent and/or legal guardian
consents to the above on my behalf below.

SIGNATURE: __Matilda Bonilla______________________________________DATE: 3/24/09_________

PRINT NAME: Matilda Bonilla___________________________________________________________________

ADDRESS: ___154 Minor St. New Haven,CT 06519

___________________________________________________________________

IF UNDER 18 YEARS OLD:

I AM THE PARENT OR GUARDIAN OF THE MINOR NAMED ABOVE AND RELEASE REAL LIFE. REAL
TALK. FOR THE MINOR AND MYSELF, AS STATED ABOVE.

SIGNATURE: _______________________________________ DATE: _________

PRINT NAME: ___________________________________________________________________

ADDRESS: ______________________________________________________________________