Kids Class Registration

Broadcast Request Form

Form for a member of the community to request that LexMedia broadcast a program.

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This field is for validation purposes and should be left unchanged.
Name*
First Last
Residence Affirmation*
- I live in Lexington
- I work in Lexington
- I have a sponsor who lives and/or works in Lexington
Sponsor Name
Sponsor Address
Program Name*
Total Running Time*
File Location*
Additional Program access information
PEG Sharing Permission
- LexMedia has permission to share this program with other PEG access stations.
Streaming/VOD Permission
- LexMedia has permission to play this program on its streaming and VOD services
Your contact information*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email
Phone
Release*
I hereby agree to indemnify and hold harmless LexMedia, the Town of Lexington, Comcast, RCN, Verizon, their officers, directors, employees and agents from all liability and expenses including legal fees, incurred as a result of cable casting this program. I warrant and represent that the program cablecast by LexMedia or played on websites used by LexMedia does not contain:

1. Any solicitation of funds, or advertising, or material designed to promote the sale of commercial products or services;
2. Any material that is obscene;
3. Any material concerning lottery information, gift enterprise or similar scheme;
4. Any material that is made unlawful by a government body;
5. Any material that is copyrighted or subject to ownership or royalty rights without necessary releases, licenses or other permission.
- I agree to these conditions
Untitled
- I agree to receive emails as described in the LexMedia privacy policy.

Kids Class Registration

Please complete the following form to register your child for our summer kids class.

Parent/Guardian Information

Child Information

Your Child's Filmmaking Style

Medical Information

Insurance Information

Emergency Contact Information

Authorized Pick-Up Information

Parent/Guardian Signature and Consent

Payment Information

Broadcast Request Form