Empower And Excel - Media Permission Form
EnE- Media Permission
Read the terms, and by entering your name into the box below, you confirm your affirmation of the policies outlined below. This constitutes your digital signature. *
I hereby consent to the use of photographs/videotape taken during the course of the Empower and Excel team’s volunteer work for publicity, promotional and/or educational purposes (including publications, presentation or broadcast via newspaper, internet, social media or other media sources). I do this with full knowledge and consent and waive all claims for compensation for use, or for damages.
Required
Name *
Your answer
Facility Name
Your answer
Age *
Your answer
Email Address *
Your answer
Address *
House Number, Street Name
Your answer
City *
City
Your answer
State *
Your answer
Zipcode *
Your answer
Country *
Your answer
Phone Number (home) *
Your answer
Phone Number(cell) *
Your answer
Digital Signature *
Your answer
Parent/Guardian's Digital Signature for under 18 *
Your answer
Check the following box to acknowledge that you have read and agree with all the terms, policies, and guidelines set forth in this document. *
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