>Media Release Form<

Media Release Form

Name *

First

Last

Email *

Phone Number *

Address 1 *

Address 2 *

City/Town *

Choose a State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code *

Date Of Birth *

I hereby consent to the use of my image, audio, and video *

• YES
• NO

The Media Can Be Used in the Following: *

• Videos
• Photos
• Email Marketing
• Social Media
• Newsletters/Magazines
• Website
• Other

I hereby agree to release all liability from this organization *

• YES
• NO

1. YOUR AGREEMENT By agreeing to this media release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box. PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

I hereby agree to the following terms and conditions *

• Yes
• No

Todays Date & Time *

Signature *

Submit