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FAX TO: 1-561-214-4165

In return for being allowed to participate in the workshop or teleseminar listed below, I hereby assign all rights to the audio, video, motion picture, and/or photographic recording(s), made of me during the workshop or teleseminar to Dirt Simple, Inc. (a Florida Corporation), and I hereby authorize the editing, re-recording, duplication, reproduction, copyright, sale, exhibition, broadcast and/or distribution of said recording(s) by Dirt Simple, Inc., for any lawful purpose whatsoever. I further waive any right to inspect or approve the finished video recording(s), audio recording(s), film(s), soundtrack(s), photograph(s), or printed matter that may be used in conjunction therewith or to the eventual use that it might be applied.

I understand that my participation in this workshop or teleseminar is voluntary and that I may at any time discontinue my involvement. I take full responsibility for my involvement in this project and the risks that it may entail (be they legal, physical, or mental), and waive any claims that may be related to or arise from my participation in this project.

I hereby certify that I am over eighteen years of age and am competent to contract in my own name insofar as the above is concerned

I have read this release, authorization and agreement, before affixing my signature below and warrant that I fully understand the contents thereof. This agreement will be governed and interpreted under the laws of the state of Florida.

Workshop/Teleseminar….. Banishing Unwanted FeelingsSeptember 16, 2006

Participant Name…………… __________________________________________

Participant Signature……… __________________________________________

Date Signed………………….. __________________________________________

Email Address………………. __________________________________________

You, Version 2.0 Serial #… ___________

My top question or concern I would like answered during this workshop is:



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Cover photo of "A Minute To Unlimit You" by PJ Eby
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