READ ALL FINE PRINT: By completing this form you are accepting full responsibility for the program content pursuant to all applicable laws, statutes and policies. You must be a Club20 member in good standing to submit programming for playback. Programs may be rejected or delayed if paperwork is incomplete or inaccurate; if media does not follow requirements set forth in the Media Formats list; or if Club20 membership is delinquent, suspended or revoked. Minors must have a parent or guardian's signature in order to submit programming. Your Playback Application is treated as a request to run both on SCVTV's television channels and on the Internet. Programming must be submitted at least seven (7) days prior to its requested run date unless special arrangements have been made with, and accepted by, SCVTV staff. Do not complete this form until you have thoroughly read the SCVTV Public Access Policies and Procedures.

Today's Date: ______/______/______

Your name: ________________________________________________________________ Club20? 

Organization (enter “self” if none): _____________________________________________ Club20? 

Mailing Address: _________________________________________________________________________

City/State/Zip: _________________________________________________________________________

Phone: __________________________ E-mail: ______________________________________________

Program name: _______________________________________________________________________

Describe the program: ______________________________________________________________

Are you the producer? Yes No

   If no, who is? Include name & contact info: _____________________________________________________

   If no, what document proves your authority to submit it? __________________________________________

Is this a series? Yes No

   If a series, how often is there a new show? Weekly Monthly Other _____________________________

Does it contain inserted advertising, underwriting or sponsorship recognition? Yes No

   If yes, describe: ___________________________________________________________________________

   If yes, enter total runtime of recognition(s): ___:___ (min:sec)

Does it contain any content that is inappropriate for children? Yes No

   If yes, describe: ___________________________________________________________________________

Exact total runtime (average, if series): ___:___:___ (hr:min:sec) Format: _______________________

Requested run day(s) & time(s): ________________________________________________________

Who is your primary audience? _______________________________________________________

MORE FINE PRINT: Each DVD and its case must be clearly marked with the title of the show, runtime and episode number, if any; together with your name, telephone number and email address. Once submitted, DVDs and/or digital media files are not returned. By your signature you are reaffirming that you have the necessary rights to distribute the program and its content, including any music and B-roll, over the cable television system(s) and the Internet. Programs which contain inserted advertising, underwriting or sponsorship recognition are subject to fees set forth in the SCVTV Fee Schedule, which may change from time to time. SCVTV cannot guarantee that you will receive the time slot(s) you have requested. SCVTV retains the right to archive a copy of your program on the Internet and to re-televise it at any time.

EVEN MORE FINE PRINT: Federal law provides that any person who transmits obscene matter over a cable system may be fined or imprisoned. It is a violation of federal and/or state law to commit libel, slander, invasion of privacy or copyright violation. Your program will be rejected if SCVTV staff believes trademark infringement or a copyright violation may occur by running it. SCVTV may not be used for the dissemination of any information, directly or indirectly, involving lotteries or games of chance as defined in Section 76.213 of the Rules of the Federal Communications Commission. You – and you alone – are responsible for the content of the program(s) you submit for playback. You agree to defend, indemnify and hold harmless SCVTV and affiliates, the City of Santa Clarita, Time Warner Cable, AT&T U-verse, their officers, directors, employees, and agents, from any and all claims which may arise from the cablecast of the program(s) you submit for playback.

I have read and understand the SCVTV Public Access Policies and Procedures and all fine print above, and I agree to be bound contractually to them. I attest that all of the statements I have made are true to the best of my knowledge.

SIGNATURE: ___________________________________________________ DATE: _______/_______/________