FIND MY FAMILY

PARTICIPANT APPLICATION & RELEASE

1. Please fill out this application and release (“Application and Release”) legibly.
2. Use dark colored ink.
3. Answer all questions honestly and to the best of your ability.
4. Please write only on the printed side of the paper, but feel free to attach
additional sheets if necessary.
5. Please note you must be at least 18 years old and you must never have been
convicted of a felony in order to apply

CONTACT INFORMATION
Your Full Name (Including Maiden and aliases)

Mobile:

Work:

E-mail:

Address:

Birth date (Age) : ( )

Gender: M F

Marital Status (Circle all that apply):

Single Married Divorced Remarried Widowed Engaged

Spouse’s Name:

Children (full names, ages and birthdates):

I am a legal resident of the United States (circle one) : Yes No

Occupation:

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SEARCH INFORMATION

WHO ARE YOU SEEKING?

WHAT IS YOUR RELATIONSHIP TO THEM

HAVE YOU EVER MET WITH THEM?

WERE YOU ADOPTED?

(If you were not adopted, what were the circumstances of your separation?)

IF YOU WERE ADOPTED PLEASE ANSWER THE FOLLOWING QUESTIONS

IF KNOWN:

BIRTH LOCATION (CITY, STATE): HOSPITAL BORN:

DO YOU HAVE A COPY OF YOUR ORGINAL BIRTH CERTIFICATE?

(IF SO PLEASE PROVIDE COPIES, NOT ORGINAL)

DO YOU HAVE A COPY OF YOUR ADMENDED BIRTH CERTIFICATE?

DO YOU HAVE COPIES OF ANY ADOPTION RECORDS?

DO YOU HAVE COPIES OF ANY RELEVANT MEDICAL RECORDS?

THE NAME OF THE ADOPTION AGENCY YOU WERE PLACED WITH?

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THE NAME OF THE SOCIAL WORKER INVOLVED IN YOUR ADOPTION:

DATE OF ADOPTION OR PLACEMENT:

DO YOU HAVE YOUR NON-IDENTIFYING INFORMATION WHICH YOU THINK

WILL HELP US WITH THE SEARCH FOR YOUR FAMILY? IF SO PLEASE LIST
DOCUMENTS. (NON- IDENTIFYING CAN BE OBTAINED THROUGH THE ADOPTION
AGENCY/STATE SERVICE THAT HANDLED YOUR CASE)

PLEASE SEND COPIES (NOT ORGINALS) OF ANY AND ALL

DOCUMENTATION, PICTURES, INFORMATION YOU HAVE THAT
WOULD HELP US IN FINDING THE PERSON YOU ARE SEEKING.
NO MATERIALS WILL BE RETURNED.

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INFORMATION ABOUT THE PERSON YOU ARE SEEKING:

NAME(S):

AGE(S):

DATE OF BIRTH:

KNOW PREVIOUS KNOWN ADDRESS(ES):

PHONE NUMBERS (PREVIOUS OR CURRENT):

SOCIAL SECURITY NUMBER:

OCCUPATION(S):

KNOWN RELATIVES, SPOUSES (CITY/STATE):

MEMBERSHIP IN CLUBS:

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FORMER SCHOOLS:

________________________________________________________________

MILITARY SERVICE RECORD:

________________________________________________________________

CRIMINAL RECORD:

________________________________________________________________

ANY ADDITIONAL INFORMATION THAT COULD BE HELPFUL IN FNDING

YOUR RELATIVE(S)?

________________________________________________________________

DO YOU HAVE ANY PHOTOS/VIDEO OF THIS PERSON? ANY LETTERS?

________________________________________________________________

HOW LONG HAS IT BEEN SINCE YOU’VE SEEN THIS PERSON?

________________________________________________________________

IS THERE ANYONE ELSE (RELATIVES, CASE WORKER, EMPLOYER,

ATTORNEY, ETC.) WHO COULD BE HELPFUL IN FINDING THIS PERSON?

1. Name:
Contact information:
Relation to Person you are seeking:

2. Name:
Contact information:
Relation to Person you are seeking:

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ABOUT YOU

HOW WILL FINDING YOUR RELATIVE CHANGE YOUR LIFE?

WHY IS IT URGENT FOR YOU TO FIND THEM NOW? (Please be detailed)

IF YOU SAW HIM/HER AGAIN, WHAT IS IT YOU WOULD LIKE TO SAY?

PLEASE CHOOSE ONE WORD TO DESCRIBE YOUR PERSONALITY AND

EXPLAIN:

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WHAT ARE YOU MOST PROUD OF IN YOUR LIFE?

WHAT ACTIVITIES DO YOU DO FOR FUN?

WHAT IS YOUR BIGGEST DREAM/ASPIRATION IN LIFE?

WHY DO YOU FEEL YOUR STORY SHOULD BE CHOSEN TO BE ON OUR

SHOW?

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ENTERTAINMENT EXPERIENCE

HAVE YOU EVER ACTED, PERFORMED OR APPEARED ON TELEVISION

OR FILM? (IF SO, PROVIDE DETAILS):

WHAT OTHER REALITY/GAME TV SHOWS HAVE YOU APPLIED TO OR

BEEN ON? PLEASE LIST SHOWS, DATES OF APPLICATION & AIRDATES:

ARE YOU CURRENTLY BEING CONSIDERED FOR ANY OTHER REALITY

SHOWS, INCLUDING ANY GAME OR CONTEST SHOWS?
(IF SO, PROVIDE DETAILS):

1.Show Title:
Show Contact information:

2.Show Title:
Show Contact information:

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MEDICAL INFORMATION

HAVE YOU EVER BEEN TREATED FOR ANY SERIOUS PHYSICAL OR

MENTAL ILLNESS(ES) OR HAD ANY SERIOUS INJURIES?

YES NO (CIRCLE ONE AND IF SO, PROVIDE DETAILS)::

ARE YOU ON ANY PRESCRIPTION MEDICATION THAT YOU TAKE ON A

REGULAR BASIS?

YES NO (CIRCLE ONE AND IF SO, PROVIDE DETAILS)::

DO YOU HAVE ANY PHYSICAL CONDITIONS, SPECIAL NEEDS, OR FEARS

THAT WE SHOULD KNOW ABOUT?: (IF SO, PROVIDE DETAILS)::

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ADDITIONAL INFORMATION
HAVE YOU EVER BEEN ARRESTED OR HAD A RESTRAINING ORDER
PLACED AGAINST YOU?

YES NO (CIRCLE ONE AND IF SO, PROVID ECHARGE AND WERE YOU
CONVICTED?)

HAVE YOU EVER BEEN CHARGED WITH A CRIME (MISDEMEANOR OR

FELONY)?

YES NO (CIRCLE ONE AND IF SO, PROVIDE DETAILS)::

HAVE YOU EVER BEEN CONVICTED OF A CRIME (MISDEMEANOR OR

FELONY), EXCLUDING TRAFFIC
VIOLATIONS?

YES NO (CIRCLE ONE AND IF SO, PROVIDE DETAILS):

HAVE YOU NOW OR HAVE YOU EVER OWNED OR APPEARED ON ANY

WEB SITES?

YES NO (CIRCLE ONE AND IF SO, PROVIDE DETAILS):

HAVE YOU EVER BEEN PARTY TO A LAWSUIT?

YES NO (CIRCLE ONE AND IF SO, PROVIDE DETAILS):

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NOMINATE SOMEONE FOR FIND MY FAMILY

IS THERE ANYONE ELSE YOU WOULD NOMINATE TO BE ON OUR SHOW?

(SOME OF THE STORIES WE ARE LOOKING FOR ARE: ADOPTED
CHILDREN IN SEARCH OF PARENTS (& vice versa), WAR VETERANS
SEEKING OTHER WAR VETERANS, HIGH SCHOOL SWEETHEARTS,
ESTRANGED FAMILY MEMBERS SEEKING TO RECONCILE, LONG LOST
SIBLINGS, TWINS SEPARATED, ETC.)

1. Name:
Contact information:
Relation to Person you are nominating:

2. Name:
Contact information:
Relation to Person you are nominating:

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I acknowledge that all of the information provided on this application is true and
accurate, and any false or misleading information submitted herein is grounds for my
immediate elimination from consideration. I agree that Clock Tower Productions, Inc.
and Straight Wharf Productions, LLC (collectively, “Producer “) have the right to
interview me in connection with my application to participate in the Series and that any
such interview may be filmed or taped. The information contained on this application,
any filmed or taped interview material and any other material submitted by me including,
but not limited to, pictures, film and videotapes (the “Material”), becomes the property of
Producer and shall not be returned, and may be used in any manner in all media,
throughout the universe, in perpetuity. I acknowledge that Producer may determine in its
absolute discretion whether or not to select me to participate in the Series and that
Producer has the right to end the audition process, or to eliminate me from further
consideration as a participant or potential participant at any time for any reason. In
connection with this application, I agree to sign such other releases, consents,
authorizations and other documents as Producer may require.

On behalf of me, my heirs, next of kin, spouse, guardians, legal representatives,

executors, administrators, successors and assigns (collectively, the “Releasing Parties”),
I release and discharge unconditionally and irrevocably Producer, the network on
which the Series will be broadcast (the “Network”) and each of their respective parent,
subsidiary and affiliated entities and the respective officers, members, directors,
officers, managers, employees, agents, licensees, successors and assigns of each of them
(collectively, the “Released Parties”) from and against any and all claims, liens,
agreements, contracts, actions, suits, costs, attorneys fees, damages, judgments, orders
and liabilities of whatever kind or nature in law, equity or otherwise, whether now
known or unknown, suspected or unsuspected, and whether or not concealed or hidden
(collectively, the “Released Claims”) arising out of or in connection with my application
to participate in the Series; my participation in the Series; any actions of me or
Producer in connection with that application or participation (including any
investigation conducted by Producer in connection with that application, whether as
specifically authorized under this release or otherwise); Producer’s selection or failure
to select me as a contestant; or Producer’s use or failure to use the Materials or my
name, voice or likeness in any manner. The Released Claims include claims for any
injury, illness, damage, loss or harm to person or property, whether based on
negligence, wrongful death, personal injury, infliction of emotional distress, products
liability, trespass, breach of contract, breach of any statutory or other duty of care
owed under applicable laws, negligent or intentional infliction of emotional distress,
libel, slander, defamation, false light, invasion of privacy, publicity or personality,
infringement of copyright or trademark or loss of earnings or potential earnings.

I and the other Releasing Parties acknowledge that there is a possibility that
subsequent to the execution of this release, I or they will discover facts or incur or suffer
claims that were unknown or unsuspected at the time this release was executed, and
which if known by me at that time may have materially affected my decision to execute
this release. I and the other Releasing Parties acknowledge and agree that by reason of
this release I and the other Releasing Parties are assuming any risk of the existence of
such unknown facts and such unknown and unsuspected claims. I and the other

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Releasing Parties have been advised of the existence of Section 1542 of the California
Civil Code, which provides:

A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH

THE CREDITOR DOES NOT KNOW OR SUSPECT TO EXIST IN
HIS FAVOR AT THE TIME OF EXECUTING THE RELEASE,
WHICH IF KNOWN BY HIM MUST HAVE MATERIALLY
AFFECTED HIS SETTLEMENT WITH THE DEBTOR.

Notwithstanding such provisions, this release shall constitute a full release in

accordance with its terms. I and the other Releasing Parties knowingly and voluntarily
waive the provisions of Section 1542, as well as any other statute, law, or rule of similar
effect of any jurisdiction throughout the world, and acknowledge and agree that this
waiver is an essential and material term of this release.

I authorize Producer to conduct drug testing, medical testing, psychological and physical
examinations of me in order to determine my fitness to participate in the Series. I further
authorize the individuals conducting such examinations of me to disclose to Producer and its
representatives all information about me obtained in connection with such examinations. I
authorize Producer to investigate, access and collect information about me and my
background, including without limitation: to secure information about my experiences from
my current and former employers, associates, friends, co-workers, family members,
educational institutions, government agencies, credit reporting agencies, and any references I
have provided; and to investigate my employment record, educational records, medical
records, government records (e.g., motor vehicle record, criminal record, civil litigation
record), employment eligibility and credit reports.

In connection with my application to audition for the Series, Producer may reveal to me or I
may otherwise obtain confidential or proprietary information regarding Producer or the
Series (“Confidential Information”). This Confidential Information may include, among
other things, information regarding the identity of other applicants and the Series format or
sponsors, or the nature or results of any Series challenge or competition. I agree that I will
not directly or indirectly at any time publish, reveal, disseminate or otherwise disclose, or
cause to be published, revealed, disseminated or otherwise disclosed any Confidential
Information to any third person, including family members and news media. I acknowledge
that if I disclose any Confidential Information, Producer and Network will suffer serious and
irreparable harm, which will entitle Producer and Network, among other remedies, to seek
injunctive relief and to recover liquidated damages in the amount of $1,000,000.

This agreement shall be governed by the laws of the state of California. By signing this
Participant Application and Release, I represent and warrant that all of the
information in this application is true and accurate and that I assent to all of the
terms and conditions set forth above.

Signature: ______________________________________ Date: _______________

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