WIPEOUT CANADA

CONTESTANT APPLICATION

GENERAL INFORMATION:

Name:

Gender:

Home address:

City:

Province:

Postal code:

Main phone: Alternate phone:

Email address:

Website address (if applicable):

Height: Weight:

Hair colour: Eye colour:

Date of birth:

Marital status:

Do you have children? How many?:

Occupation:

BACKGROUND INFORMATION:

Have you ever been treated for any serious illness (es) or had any serious injuries?
Yes No.

If yes, please describe in detail, citing dates, diagnosis and any on-going problems:

Are you on any medication that you must take on a regular basis?
Yes No
If yes, please describe in detail:

Have you ever been treated for stress-induced asthma, heart conditions, or high blood pressure?
Yes No
If yes, please describe in detail:
Do you have any phobias (ie. fear of heights)?
Yes No
If yes, please describe in detail:

Please list all television shows that you have appeared on. Even if you did not win anything,
you must disclose all television appearances.
Show(s)
Network(s)
Approximate Air Date(s)
Role(s) in Show(s)
Prizes Won:

Have you ever been charged with or convicted of any crimes?

Yes No
If yes, please describe in detail:

Have you ever been convicted of any crimes?

Yes No
If yes, please describe in detail:

CONTESTANT QUESTIONNAIRE:
Please complete to the best of your ability. We want your personality to shine through,
so be creative, and have fun. We want to get to know you! Anything you can do to get our
attention is fantastic!

Do you work out? If so, what types of activities and how often? (Be as specific as possible)

What sports organizations have you been a member of? (i.e., High School; College; Minors;
Professional; etc...,please list all that apply and the levels played)

Where did you go to university or post-secondary education? (if applicable)

Do you have an advanced degree in any field or are studying for one? (Graduate degree or Doctorate)

Have you ever won any academic prizes or scholarships? If so, what?

Have you ever had your IQ tested to join an organization like Mensa? If so, what did you get?

Does your job require you to wear a uniform? Would you be prepared to wear a version of that uniform
on the course?

Where were you born?

Would you consider yourself “big city” or “small town”? Why?

Have you ever entered a beauty contest? If so, how did you do?
Do you have siblings, parents or children who might also be interested in appearing on Wipeout Canada?
If so, can you get them to apply? If they have applied, what are their names?

Are you in a relationship?

Yes No
If yes, how long have you been in your current relationship?

If yes, would your partner also be interested in appearing as a contestant on Wipeout Canada?
Has he or she applied?

What is the next big milestone in your life?

What would your friends say are your best qualities?

What would your friends say are your worst qualities?

How are you competitive in your every day life?

Have you had any experiences that have traumatized you? If yes, please explain:

What is your unique and personal motivation for wanting to compete on the show?

How would you use your Wipeout Canada winnings?

Do you have a nickname? What is it?

What would your Wipeout Canada nickname be?

What would your Wipeout Canada ‘shout out’ be when you start the course?

If you were a superhero, what would your superpower be?

Are you willing to wear a costume while competing on Wipeout Canada?

If yes, what would your costume be?

What would be the worst, most embarrassing and humiliating thing that could happen to you on
Wipeout Canada? Visualize it - now tell us the story.

Do you believe in an afterlife?

Do you believe in life on other planets?

Do you think you will win Wipeout Canada? If so, why?

What qualities will the winner of Wipeout Canada possess?

What are your other favourite TV shows?

Who is your greatest hero?

Why should Canadians cheer for you?

If you were an animal, what kind of animal would you be?

If you were a food, what kind of food would you be?

Do you have an unusual skill or talent?

What is the most daring and dangerous thing you have ever done? Describe the circumstances:

What is the coolest thing about you?

What is the weirdest thing about you?

What other TV shows have you applied for? List the shows and month/year:

Are you currently being considered for any other TV shows? If yes, please explain:

UPLOAD PHOTOS: current, non-professional head shot and full body shot

UPLOAD VIDEO LINK: (video link is optional, but remember, we see lots of applications.
Anything you can do to get our attention gives you a better shot! So be creative: sing a song,
show us your battle cry for the start of the course, do your "I just won" victory dance…don't be
afraid to think outside the box!)

Contestant Selection Process:

A. Applicants applying to be contestants must complete and sign this application

and may be required to attend one (1) or more audition/interview sessions.

1817141 Ontario Inc. ("Producer"), in its sole discretion, will determine who among the
people who have applied will be placed into the pool of eligible potential contestants
(“Audition Player Pool”).

Producer, in its sole discretion, shall select people from the Audition Player Pool to become
short listed potential candidates for episodes of the program (each, a “Finalist”).

B. Selection of Finalists and actual contestants chosen shall be made by Producer based on
such criteria as it shall determine in its sole discretion, which may be subjective.

Producer is not obligated to select anyone, even if someone meets all eligibility
requirements and all criteria for selection.

Producer’s decisions regarding the selection of Finalists and contestants are final and not
subject to challenge or appeal.
Producer is not obligated to have any contestant appear on the program
and Producer shall have the right at all times and in its sole discretion to remove
or replace any contestant for any reason or no reason. Even if a contestant
participates in the program or any part thereof, Producer is not obligated to
broadcast or otherwise use or exploit the program, such contestant’s participation
therein or any part thereof.

C. All Finalists must sign and return the Contestant Agreement and Release, Series Rules, a
confidentiality agreement, and any waivers, authorizations and other documents as may be
required by Producer and Canwest Television Limited Partnership and/or any of their
licensees, successors and assigns.

D. Any applicant who refuses to sign any of the documents requested by Producer shall be
ineligible to participate on the program and/or is subject to disqualification from the
program. I acknowledge that all of the information provided on this questionnaire is true
and accurate, and any false or misleading information submitted herein is grounds for my
immediate dismissal from the contestant selection process, and/or from the program, if
selected.

I agree that Producer has the right to interview or audition me in connection

with my application to participate in the program and that any such interview may be
filmed or taped. The information contained on this questionnaire, any filmed or taped
interview material and any other material submitted by me including, but not limited to,
pictures, film and videotapes, 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 understand that it is forbidden to give or agree to give any member of the production staff
and anyone associated in any manner with the program, or any representative of the
Producers any portion of my compensation or anything else of value to arrange my
appearance on the program or to accept or agree to accept anything of value to promote
any product, service or venture on the program, or use any prepared material containing
such a promotion where I know the writer received consideration for such material.

By signing this questionnaire, I represent and warrant that I meet and will meet all
of the Eligibility Requirements, that all of the information in this questionnaire is
true and accurate and that I assent to all of the terms and conditions set forth above.

Signature: ______________________________________ Date:____________________

Please sign and date the following

NAME AND LIKENESS AND LIABILITY RELEASE

AND TRANSFER OF RIGHTS:

For good and valuable consideration, the receipt and sufficiency of which is hereby
acknowledged, I hereby consent to the recording, use, reuse, transmission, exhibition,
broadcast and other exploitation in whole or in part and in any language of my voice,
actions, likeness, name, appearance, biographical material, and any information contained
in this or any other application to be a participant in the program or in any materials
submitted by me in connection with my application (collectively "Likeness") by 1817141
Ontario Inc. ("Producer"), Lone Eagle Entertainment Ltd., Canwest Television Limited
Partnership, Endemol Argentina S.A., Endemol USA Inc., any station airing the program,
and/or any of their respective parents, subsidiaries, or affiliated companies, licensees,
partners and assigns and the officers, directors, employees, agents and representatives of
any of them (jointly and severally, "Releasees") by any means and in any medium now
known or hereafter devised throughout the universe in perpetuity.

Producer shall own exclusively all right, title, and interest (including, without limitation, all
copyrights) in and to any written, spoken, videotaped or other materials that I have
provided or may provide to Producer in connection with my application, the program, or
otherwise (collectively, the "Materials")
including, without limitation, the right to edit, alter or modify the Materials.

Producer and Canwest Television Limited Partnership shall have the exclusive, perpetual
right to use and to assign to third parties, including without limitation any other
broadcaster or exhibitor of the program, the right to use my Likeness and the Materials in
and in connection with the program and/or other programs, any promotion, publicity,
marketing or advertising for the program and/or other programs by any means and in any
medium now known or hereafter devised, in commercial tie-ins, for informational
purposes and/or for general advertising and promotional purposes.

I grant the rights hereunder whether or not I am selected to participate in the program. I
agree to release, defend, indemnify and hold harmless Releasees from and against any and
all claims, actions, lawsuits, liabilities and expenses (including reasonable attorneys fees)
arising out of or relating to the program application and selection process and/or the
recording or use of my Likeness and/or the Materials (including, without limitation, any
claim that such use is defamatory, inflicts emotional distress 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 agreement, the sole consideration for which being Producer’s consideration of
me as a possible contestant, which I acknowledge is good, valuable and sufficient.

I have signed this release on the ____________ day of _______________________, 2010.

Signature_________________________________________________________
Name (Please print or
type)___________________________________________

Thank you for your time and effort in completing the form. Good Luck!