DATE: _____/______/2004

PRODUCER: ___________________

Video Shoot Release Form and Limited Liability Release Form

“BRAIN JUICE BUKKAKE”

I, _________________________, hereby acknowledge that I am participating in a motion picture being produced by ________________________, for Holy Squirrel Films.

SHOOT RELEASE: I hereby irrevocably grant to David Harder, and to Holy Squirrel Films, its licensees, agents, successors and assigns, the right, but not the obligation, in perpetuity throughout the world and in all media, now or hereafter known, to use (in any manner it deems appropriate, and without limitation) in and in connection with the motion picture, by whatever means exhibited, advertised or exploited:

1) my appearance in the motion picture, still photographs of me, recordings of my voice taken or made

of me by it, any music sung or played by me, and my actual or fictitious name; and/or

2) the appearance of the location or property known as: _________________________, of which I

am the owner and/or manager with the power to so grant; and/or

3) the song or music, known as ______________________________________ performed by

__________________, for which I have the authority to grant**.

**Use of song or music by Holy Squirrel Films, is strictly limited to the film/video referenced

herein.

Furthermore, I acknowledge that Holy Squirrel Films, or its assigns may shoot behind the scenes “making of the film” footage, for use in a motion picture, and I hereby irrevocably grant to Holy Squirrel Films, its licensees, agents, successors and assigns, the right, but not the obligation, in perpetuity throughout the world and in all media, now or hereafter known, to use (in any manner it deems appropriate, and without limitation) in and in connection with the motion picture, by whatever means exhibited, advertised or exploited: my appearance in the motion picture, still photographs of me, recordings of my voice taken or made of me by it, any music sung or played by me, and my actual or fictitious name.

LIMITED LIABILITY: Furthermore, I understand that during my participation in the production of Brain Juice Bukkake, I may be exposed to a variety of hazards and risks, foreseen and unforeseen, that may include, but are not limited to, personal injury, property damage and death. To the fullest extent allowed by law, I agree to waive, discharge claims and release from liability Holy Squirrel Films., its officers, directors, employees, agents and leaders from any and all liability on account of, or in any way resulting from Injuries or Damages. I understand and intend that this assumption of risk and release is binding upon my heirs, executors, administrators and assigns, and includes any minors accompanying me on the production.

______________________________  ___________________________

Name                                                               Address

_______________________________ ___________________________

Signature

(Signature of parent/guardian if under 18

______________________

                                                                                    Phone