Complete this form for all OFF CAMPUS Student Film Production Shoots at least 21 DAYS in advance of the shoot. THIS FORM MUST BE COMPLETED BY A STUDENT WHO IS RECEIVING ACADEMIC CREDIT for the course to which the project satisfies a requirement.
STUDENT/PARTICIPANT INFORMATION:






RELEASE WAIVERS FOR MINORS:
A Release Waiver must be signed by parent/guardian PRIOR TO the minor participating in the shoot. You must use the template form located on the Risk Management Website at: https://www.ithaca.edu/riskmanagement/docs/waiver18_minors/. The signed release waiver must be retained by the Dean's Office. Transportation of the minor to and from the shoot is the responsibility of the parent/guardian. The parent/guardian must remain on location with their minor during the shoot at all times.
NYS REQUIREMENTS FOR MINORS IN FILM SHOOTS/PRODUCTIONS:
No minor (less than 18 years of age) may participate or be employed in film shoot and/or production without first obtaining a valid Child Performer Permit, issued by the Commissioner for the New York State Department of Labor.
• A minor may obtain a 15-day Temporary Child Performer Permit only once.
• A minor must obtain a 12-month Child Performer Permit if they have ever previously had the Temporary Child Performer Permit.
• The Temporary Child Performer Permit can be found and completed, at no charge, on the NYS Department of Labor website, at: https://www.labor.ny.gov/secure/ChildPerformer/welcome.html
• Minors may not be employed for compensation for student productions.
OTHER STATES: All film shoots/productions in OTHER STATES must comply with state-specific requirements if they involve minors. Contact the Dean's Office for assistance addressing those requirements. Proof of compliance must be filed with the Dean's Office.
PLEASE NOTE: ACTION AND PROPS OF CONCERN ARE SUBJECT TO REVIEW AND APPROVAL BY THE DEAN'S OFFICE.
PLEASE NOTE: SCENES SIMULATING VIOLENT ACTIONS AND/OR INVOLVING CHOREOGRAPHED FIGHT SCENES, WEAPONRY, ETC., MUST BE REVIEWED AND APPROVED BY YOUR INSTRUCTOR, PRIOR TO FILMING.

















LOCATION INFORMATION - FIELDS ARE PROVIDED FOR UP TO THREE LOCATIONS.
DO NOT OFFER TO PROVIDE INSURANCE. THE COLLEGE ONLY PROVIDES EVIDENCE OF INSURANCE, VIA A CERTIFICATE OF INSURANCE, WHEN THE BUSINESS AND/OR INDIVIDUAL SPECIFICALLY REQUIRES IT, USUALLY BY CONTRACT/AGREEMENT.
This is not an all inclusive list, but please be advised certain locations and areas will not be approved, such as rooftops, on water, near trains, and similar higher risk locations.
Please complete all fields for each location. Space is provided for up to three locations; if have only have one location, complete all necessary fields for Location 1 and proceed to Assumption of Risk and Responsibility Section.
LOCATION # 1 INFORMATION
Pick a date
Pick a date
Pick a date
Pick a date











LOCATION 2:
Pick a date
Pick a date
Pick a date
Pick a date











LOCATION 3:
Pick a date
Pick a date
Pick a date
Pick a date
ASSUMPTION OF RISK AND RESPONSIBILITY: I understand that I will be responsible for any and all damages or losses to College-owned property while in my care, custody, and control, due to my own negligent acts or negligent acts of others who participate in my shoot; that I am fully responsible for any and all expenses, losses or damages to equipment from an outside rental company; that I am responsible for any and all injuries and third-party property damages or losses resulting from my own negligent acts or the negligent acts of others who participate in my shoot, and that I must report any and all injuries and/or property damages immediately to the Office of Public Safety at 607-274-3333.
I hereby affirm that I have provided a complete and accurate script for this film shoot/production to my instructor (for the course to which the project satisfies a requirement), and obtained their approval. I further understand that, before I begin the off-campus shoot/production, I must first obtain approval from the Dean’s Office in response to this form.
I hereby verify that all information is true and acknowledge that any false information provided is the equivalent of Academic Dishonesty, for which I could be subject to judicial referral and cancellation of all College-owned production equipment checkout.
I agree, and it is my intent, to sign this document and affirmation by clicking the box below marked I AGREE. By electronically submitting this document I understand that my signing and submitting this document in this fashion is the legal equivalent of having placed my handwritten signature on the submitted document and this affirmation. I understand and agree that by electronically signing and submitting this document in this fashion I am attesting to the truth of the information contained therein.
 
After you click submit please scroll back up to the top, you should receive a message confirming submission of the form, if you do not then the form may not have been transmitted.