Submissions Facebook Instagram My Name is NOT Mom Step 1 of 2 50% 1. Grant of Rights:*For good and valuable consideration, receipt of which is hereby acknowledged, I irrevocably grant to My Name is NOT Mom, LLC and its owners, principals, agents, employees, licensees, affiliated and related companies and assigns collectively and individually "MNINM" the following rights (hereinafter "Rights and Materials") for use in or in connection with promotional/private use: to interview me (on and off-camera), to record on film, tape or otherwise the following: my name, likeness, image and/or voice; my on and off camera interview(s), story(ies) and performance(s); photographs taken of me and/or provided by me; and other material or information provided by me; my biographical material; and my surroundings (to the extent such occurs in my home or place where I have possession). I acknowledge and further agree that MNINM has the perpetual, irrevocable and unencumbered right (but not the obligation) to use, distribute and exhibit (and/or to authorize others to use, distribute and exhibit) all or part of the Rights and Materials in any and all media now known or hereafter discovered, in perpetuity, throughout the world, and in the promotion, marketing, publicizing and exploitation thereof, including subsidiary, allied and ancillary rights therein, throughout the universe in all media and by all technologies, whether now known or hereafter devised (including, but not limited to, the Internet via videostreams, in podcasts and in transmissions to mobile devices) and in television, radio, and other advertisements and promotions for Promotional/Private use (the "Advertisements") in perpetuity; and to edit the Rights and Materials as MNINM wishes. I also understand and agree that MNINM may assign this Agreement in whole or part and the rights granted herein shall inure to the benefit of MNINM, its licensees, successors, and agents. I acknowledge & Accept 2. Release:*I agree to never sue MNINM or anyone connected in any way to MNINM because 1) MNINM did not accept or use the Rights and Materials given by me; or 2) I do not like the manner in which MNINM or anyone connected in any way to MNINM utilized the Rights and Materials given by me. I hereby release MNINM from and against any and all claims, demands and causes of action of every kind and nature, which I may now have or may hereafter acquire, arising out of or in connection with my appearance and participation in promotional/private use, including without limitation, any claims, demands and cause of action for invasion of privacy or publicity, defamation, infliction of emotional distress and any other tort in connection therewith. I acknowledge & Accept 3. No Revocation:*I acknowledge that MNINM will rely upon the release granted hereunder and, accordingly, agree that my authorization and release hereunder shall be irrevocable by me. I acknowledge & Accept 4. Entire Agreement:*In signing this Appearance Authorization and Release, I have not relied on any representations or other statements which are not contained in this Appearance Authorization and Release. I understand and agree that no oral agreements are binding unless and until reduced to writing and signed by a duly authorized representative or officers of MNINM. I acknowledge & Accept 5. Other:*MNINM shall exclusively own the copyright in and to any use and/or recordings made utilizing the Rights and Materials. MNINM has complete and sole discretion as to the use of the Rights and Materials. I represent and warrant that I have the full right, power and authority to grant the rights herein granted. Under penalties of perjury I certify that the information, materials and representations given or made by me, which are contained on this form, are true and correct. I am not, nor do I intend to be in the foreseeable future a candidate for public office. Unless counter-signed below by my parent or guardian, I am at least 18 years of age. This Appearance Authorization and Release shall be governed by the laws of the State of New York, whose courts shall have exclusive jurisdiction over this document. I understand that upon my execution of this Agreement, a duly authorized officer of MNINM will counter-execute this Agreement. I acknowledge & Accept COMPLETE THIS ONLY IF YOUR VIDEO SUBMISSION INCLUDES FOOTAGE OF YOUR CHILD(REN) There are "No" children in my submission There "Are" children in my submission I am the parent/guardian of __________________________ (print full name[s] of child[ren]) (“My Children”). I hereby grant to MNINM, on behalf of My Children, all rights and releases set forth hereinabove for which I have executed this submission form.My Child[ren] Name[s]*Please insert every child's full name on a separate line.First Name* First NameLast Name* Last NameDate of Birth* MM slash DD slash YYYY HiddenSubmission Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone* Below is a list of questions you can choose from. Feel free to answer some or all the questions. One question per entry. Feel free to submit multiple times. Instructions: 1. Shoot horizontally….that’s long ways side to side. 2. Be sure to speak loudly. The video won’t be funny if we can’t hear you. 3. Be sure you are well lit and there is no light behind you. Video Option* What's the most embarrassing thing your kid told their teacher about you? How have you inconvenienced your middle schooler today? How bad does your high schooler smell? How would your child react if you took away their phone? Give us your best impression of a toddler/ elementary school….Middle school….or high school kid breakdown. What is one thing you say over and over to your kids? What are some dumb questions your kid asks you? Share your favorite mom story. (ie…an embarrassing, break down, funny or endearing story) What is the one thing you wish people told you BEFORE you had toddler/ middle schooler/ high schooler Submission*Accepted file types: mov, mp4, avi, Max. file size: 128 MB.