You Deserve It - Contestant Application - Part I of III

IT IS CRUCIAL THAT YOUR APPLICATION MUST BE KEPT SECRET
FROM THE PERSON YOU ARE PLAYING FOR.
IF NOT YOU WILL BE AUTOMATICALLY INELIGIBLE.

Your Full Name:

First:  Last:

Current Address:

Street:

City: State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip:

Phone:

Cell: () - Alternate: () -

Email:

Primary:  Alternate:

Emergency Contact:

First:  Last:

Phone: () -

Date of Birth:

Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911

Marital status:

Married Single Divorced Widowed

Work:

Occupation:

Current Employer:

The following are ALL of the television programs (including, without limitation, all talk, game, and reality programs) on which you have EVER appeared, whether broadcast or not broadcast:
Please estimate dates if you are unsure.

Name of Show:	Tape Date:	Air Date:
	Month January February March April May June July August September October November December Year 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980	Month January February March April May June July August September October November December Year 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980
	Month January February March April May June July August September October November December Year 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980	Month January February March April May June July August September October November December Year 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980
	Month January February March April May June July August September October November December Year 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980	Month January February March April May June July August September October November December Year 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980

If you have appeared on more than three shows, please list additional appearances:

Are you currently being considered for any other game show or reality program?
Yes No   If yes, please include air/tape date:
Please estimate dates if you are unsure.

Name of Show:	Tape Date:	Air Date:
	Month January February March April May June July August September October November December Year 2012 2011	Month January February March April May June July August September October November December Year 2012 2011
	Month January February March April May June July August September October November December Year 2012 2011	Month January February March April May June July August September October November December Year 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980
	Month January February March April May June July August September October November December Year 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980	Month January February March April May June July August September October November December Year 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980

If you are being considered for more than three shows, please list additional all others:

Are you professionally trained or have you appeared as an entertainer?
Yes No   If yes, please describe your training and/or appearance(s):

What makes you a good contestant for our show?

Who are you playing for?

First:  Last:

Why do they deserve to win this money?

Has the person you're doing this for done anything for you or others? Tell us what and when:

How much money would make a real change in their life, and what would they do with it?

RELEASE, CONSENT AND ELIGIBILITY REQUIREMENTS:

Background

1) You must be at least 18 years of age and be a legal resident of one of the fifty (50) U.S. states or Washington, D.C., and currently live in the United States.

2) You must never have been convicted of a felony. You must not currently have any outstanding warrants or restraining orders against you.

3) You must not have appeared on any television game or reality show that has been broadcast within one (1) year prior to the date hereof.

4) Neither you nor any member of your immediate family or anyone living in your household is currently employed by or has been employed within the last two (2) years by any of the following:
   (i) Kinpro LLC, Kinetic Content, LLC, Enteractive Solutions Group, Inc. or Sullivan Compliance Company, or any of their respective parent, subsidiary, or affiliated companies, or any division or agent of any of them;
   (ii) Any officer, agent, representative or employee of Producer or any person or entity involved with the program;
   (iii) Any known major sponsor of the program or its advertising agency;
   (iv) Any person or entity supplying prizes or other services to the production, administration, judging, or exhibition of the program;
   (v) ABC or its parent, subsidiary, related and affiliated entities or broadcast affiliates.
You acknowledge and agree that Producer has the sole discretion to render ineligible or disqualify any person who, in Producer's sole discretion, is sufficiently acquainted with any person or entity connected with the production, administration, judging or exhibition of the program such that your participation in the program could create the appearance of impropriety.

5) To the best of your knowledge, is there anyone you know or have known (other than members of your immediate family and anyone living in my household, who are subject to the representation and warranty that you have made pursuant to Paragraph 4 above) who is an officer, director, or employee, or was, within the past year, an officer, director, or employee of:
   (a) Producer, Kinetic Content, LLC, Enteractive Solutions Group, Inc., Sullivan Compliance Company or any of their respective parent, subsidiary, or affiliated companies, or any division or agent of any of them;
   (b) Any officer, agent, representative or employee of Producer or any person or entity involved with the Program;
   (c) Any known major sponsor of the Program or its advertising agency; (d) Any television station or channel, cable network, or satellite network that airs the Program or any entity of which such station, network or channel is a parent, subsidiary, affiliate or division;
   (e) Any person or entity supplying prizes or other services to the Program;
   (f) ABC or its parent, subsidiary, related and affiliated entities or broadcast affiliates.
Yes No

If yes, please list all such persons below:

6) You are not a candidate for public office and agree that you will not become a candidate for public office from the date hereof until one (1) year after the initial broadcast of the episode of the program in which you appear (if any).

7) If you are selected by Producer to be a contestant on the program, you agree to be available to participate as a contestant in connection with the production of the program in the Los Angeles, California area, tentatively spring, 2012, and be willing to travel to various locations as part of production, as and to the extent required by Producer. The exact dates are subject to change and to be determined by Producer in its sole discretion and continuing until the completion of your participation on the program as required by Producer.

8) You have not appeared on any television game or reality show that is intended to be broadcast within one (1) year after the date hereof. You have listed above all of the game or reality shows for which you have applied to be a contestant or participant. You will not apply to be on any other game or reality show while still being considered for the program or after being selected to be a contestant on the program.

Consents and Releases

9) If selected as a participant you must execute waivers, consents and release agreements required by ABC and/or Producer or any of their respective licensees, successors or assigns.

10) You must be willing to submit to a background check.

11) You hereby give the following representations, warranties, acknowledgements, consents and releases:
   (a) By signing below, I hereby represent, warrant, acknowledge, and agree that: (i) I have read and I meet and agree to be bound by the eligibility requirements; (ii) I have completed this application honestly and accurately; (iii) if any of the information in this application is found to be false or incomplete, this will be grounds for dismissal from the Program contestant selection process, and/or from the Program contest, if selected; (iv) even if I meet the eligibility requirements, Producer has no obligation to interview me, and/or select me as a contestant; (v) even if I am selected as a contestant, Producer has no obligation to conduct the contest or produce the Program and ABC has no obligation to broadcast it, even if produced; (vi) all decisions by Producer concerning selection of the contestants is final and not subject to challenge or appeal; and (vii) Producer has no obligation to return any materials submitted by me as part of the application whether or not I am selected as a contestant.
   (b) By submitting this application, I hereby consent to the recording, use and reuse by Producer, ABC, the Walt Disney Company, Interactive Solutions Group, Inc., Sullivan Compliance Company, known sponsors of the program or its advertising agencies and any of their respective licensees, successors, assignees, parents, subsidiaries, or affiliated entities, and each of their respective employees, agents, representative, officers and directors (collectively "Releasees") of my voice, actions, likeness, name, appearance, biographical material, and any information contained in, derived from or obtained in connection with my application to be a contestant in the Program or in any materials submitted by me in connection with my application (collectively "Likeness"), as edited, altered, or modified by the Producer or by any of the other Releasees, in any and all media now known or hereafter devised, worldwide in perpetuity, in or in connection with the Program. I agree that the Releasees or any of them may use all or any part of my Likeness, and may alter or modify it regardless of whether or not I am recognizable. I further agree that the Releasees exclusively own all right, title, and interest (including, without limitation, all copyrights) in and to any and all recordings made by them and in and to any and all video that I have provided in connection with my application and any other materials that I have provided or may provide in connection with my application or the Program (collectively, the "Materials"), including, without limitation, the right to edit, alter or modify the Materials and to use all or part of the Materials and my Likeness in any and all media now known or hereafter devised worldwide, in perpetuity. I further agree that Releasees may use my Likeness and the Materials in connection with any promotion, publicity, marketing or advertisement for the Program. I grant the rights hereunder whether or not I am selected to participate in the Program in any manner whatsoever. I, my heirs, next of kin, spouse, guardians, legal representatives, executors, administrators, successors and assigns (collectively, "Releasing Parties"), release Releasees from any and all liability arising out of or in connection with the recording or use of my Likeness and/or the Materials, my preparation for, participation or appearance in, elimination from, travel in connection with, or activities associated with the program, any use of any prize or gift awarded to the beneficiary in connection with the program, beneficiary's loss of any benefits including without limitation, Medicaid, SSI and SDI, Producer's production and exploitation of the program, or Producer's or ABC's exercise of any rights granted by me in this casting application, on any legal theory whatsoever, whether occurring before, during or after my actual participation in the program. The released claims shall include, without limitation, claims arising out of or in connection with any injury, illness, damage, loss or harm to me or my property, or my death, or any injury, illness, damage, loss or harm to any Releasing Parties or any third parties or any of their property, or the death of any Releasing Parties or any third parties, any eligibility determination, any disqualification determination, any exploitation of the program or my appearance on the program, the failure of Producer to select me as a contestant and/or the cancellation of the program. The released claims shall include, but are not limited to, those based on negligence or gross negligence of any of the Releasees or any of the other contestants in the program, infliction of emotional distress (both negligent and intentional), breach of contract, breach of any statutory or other duty of care owed under applicable laws, libel, slander, defamation, invasion of privacy, publicity or personality, misrepresentation, infringement of copyright, loss of earnings or potential earnings, and/or any and all claims, actions, damages, liabilities, losses, costs and expenses of any kind resulting from the actions of the Releasees, or any of them, or any other contestant or any other third party, at any time. I agree not to make any claim against Releasees as a result of the recording or use of my Likeness and/or the Materials (including, without limitation, any claim that such use defames me or invades any right of privacy and/or publicity). I understand that I will not be paid any money for giving Releasees these rights or for signing this application.
   (c) I hereby authorize Producer and/or any person or entity designated by Producer to investigate, access and collect information about me, about any of the statements made by me in my application, this application, any supporting documents and any other documents that I have signed or provided or do sign or provide in connection with my application to be selected as a contestant in the Program, or any other written or oral statements I make in connection therewith. I irrevocably authorize Producer and any person or entity designated by Producer to secure information about me and my experiences from my current and former employers, associates, friends, family members, educational institutions, government agencies, credit reporting agencies, and any references I have provided, and I irrevocably authorize such parties to provide information concerning me. I hereby unconditionally and irrevocably release and forever discharge Releasees, the persons or entities designated by Producer, and all such parties and persons from any and all liabilities arising out of or in connection with any such investigation. I specifically authorize investigation of my employment records and government records, including but not limited to my motor vehicle records, criminal records and credit and/or consumer report(s). I acknowledge and agree that any such information obtained by Producer or by any person or entity designated by Producer pursuant to this paragraph or otherwise may be used for purposes of selecting contestants in the Program, and may be described or otherwise related in and in connection with the Program.
   (d) I hereby authorize Producer and/or any person or entity designated by Producer to conduct psychological and physical examinations of me as required by Producer. I further authorize the individuals conducting such examinations of me to disclose to Producer and their representatives all information about me obtained in connection with such examinations, and authorize Producer to utilize such information in selecting contestants for the Program.
   (e) I acknowledge, understand and agree that my submission of this application may cause Producer to disclose information to third persons connected with the program and to compile information from third parties in connection with such application and the application process about my private, personal and public life, personal relationships with third persons, my educational and employment history, my criminal history and the like (collectively, "Personal History"). I acknowledge and agree that my Personal History may be revealed by Producer to third parties in the course of the application process and/or the program and that I release, discharge and hold harmless Releasees from any and all claims and damages arising from such complication or disclosure of Personal History.
   (f) I shall treat all information and material received or acquired about Producer and the program (including, without limitation, the application process) as strictly confidential and shall not disclose or disseminate any such information to any third party. I will keep strictly confidential all aspects of your participation in the program including but not limited to the casting process and not share any information whatsoever regarding the program with the "beneficiary" I am playing for, under penalty of disqualification. I recognize that a breach by me of this paragraph would cause Producer irreparable injury and damage that cannot be reasonably or adequately compensated for by damages in an action at law; and, therefore, I hereby expressly agree that Producer shall be entitled to injunctive and other equitable relief to prevent and/or cure any breach or threatened breach of this paragraph by me.
   (g) I acknowledge that all decisions concerning the selection of participants in the program are final and are not subject to challenge or appeal.

"I have read, understand, and agree with the foregoing."

Sign by entering your full name and today's date:

Full Name: Date:

On the next page you will upload your photograph.

IP Address: 38.107.179.212

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