Revised 10/28/2014
Please complete for all Film Shoots (on & off campus); one form for each location. Submit to Risk Management, 319
Peggy Ryan Williams Center, 20 days before shoot start date. Print legibly and provide as much detail as possible.
COURSE NAME AND NUMBER: ______________________________________________________________________
INSTRUCTOR’S AUTHORIZATION: I, ______________________________________________________, (print name)
acknowledge that the student, shown below, is completing this film shoot as a course requirement and that I have
reviewed the content of this shoot.
INSTRUCTOR’S SIGNATURE: ___________________________________________DATE:______________
Student Name: _______________________________________ Student ID #:___________________________________
Phone # _______/_______/_________ IC Email Address: ___________________________________________________
Film Shoot Title: ____________________________________________________________________________________
Student MUST provide a full detailed description of the action and/or any props used in the film shoot: (Action ex;
running, jumping, walking, sitting, dancing. Props ex; books, balloons, umbrellas, flowers, balls, chairs, tables, etc)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Will any of the following be used: Prop Gun, Dagger, Sword, Knife, Weapon or Vehicle? Yes ______ or No ______
If yes, provide specific make, model, color etc.____________________________________________________________
___________________________________________________________________________________________________
Specific Address/Location of Shoot (On or Off Campus): __________________________________________________
___________________________________________________________________________________________________
Date: _____/_____/______
Date: _____/_____/______
Date: _____/_____/______
Date: _____/_____/______
Start Time:
Start Time:
Start Time:
Start Time:
____:_____
____:_____
____:_____
____:_____
am/pm End Time ____:____ am/pm
am/pm End Time ____:____ am/pm
am/pm End Time ____:____ am/pm
am/pm End Time ____:____ am/pm
Total # of people involved in shoot: _________ # of participants that are NON Ithaca College students? ___________
Please explain: ______________________________________________________________________________________
Will there be any participants under age 18? Yes _____ or No _____ If yes, a parental waiver MUST be signed.
For Off Campus Shoots: Provide Exact Name & Address of Organization. TYPE or PRINT LEGIBLY.
Name __________________________________________________________________________
Address ________________________________________________________________________
City _____________________________________________State___________Zip_____________
ATTENTION:
_______________________________________________________________________
Phone number: _______/________/____________ FAX number: ______ _/_______/_____________
EMAIL Address: ________________________________________________________________________
Does the organization require you (student) or Ithaca College to sign any documentation? Yes ____ or No _____
If yes, before proceeding you must consult with Risk Management by calling 607-274-3285.
Does the organization require proof of insurance? Yes_____ No_____ Additional Insured? Yes _____or No _____
The Organization’s preferred method to receive the Certificate of Insurance. (Please Circle One) E-Mail or Fax
I understand and agree that by signing I have reviewed all film shoot content/script with my professor; that I will be responsible for
any and all damages or losses to College-owned property while in my care, custody & 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 co.; that I am responsible for any and all injuries and 3rd party property damage or losses
resulting from my own negligent acts or negligent acts of others who participate in my shoot; and I understand that my shoot must be
approved by Risk Management and the Office of Public Safety prior to proceeding.
Student Signature: _________________________________________________________ Date: _____/_____/_______