I Survived...

This is a legal document affecting your rights and responsibilities:
please read it carefully before signing.

I,  agree to complete and submit this story submission form (the "Form") for the purpose of being considered to become a participant in the television show entitled "I Survived..." (the "Program"). I am making the representations, disclosures, and agreements described below in this Form so that Producer will continue to consider me to become a participant in the Series. If any disclosure or representation is false, misleading or incomplete, or if I breach any agreement made in connection with the Series, Producer may remove me from further consideration as a participant. I agree that I have not made, nor will I ever make any false or misleading statements regarding the Program, my participation in the Program, or the person that I am submitting for appearance in the Program ("Subject"). I agree that I have not, nor will I engage in any deceptive or dishonest act with respect to the Program, including but not limited to informing the Subject about the intervention or offer of treatment, the intended outcome of the Program, or any confidential knowledge I have with respect to the Program.

Please type in your NAME here which signifies that you are agreeing to the above terms of the Story Submission Form: 

 Please check this box which signifies that you are agreeing to the above terms of the Story Submission Form.

Confirmation Phone (same as phone above):     

Date:      (mm/dd/yyyy)

Person who is the subject of the story: 

Additional Materials Supplied: 
(Do not exceed 60 characters)
If none, please type in NA