Under the Big Top Music Camp

Number of Children attending (required)

Names and Ages of Children attending (required)

Parent/Guardian Information

Your Name (required)

Your email (required)

Your Mobile/Cellphone (required)

Your Secondary Phone (required)

Your Address (required)

Secondary Parent/Guardian Contact Information (optional)

Allergies/Limitations

Does your child have any allergies/limitations we need to be aware of? (required)

Photo Release

Photo Release (optional)
I,, hereby grant and authorize West Baptist Church the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or videos taken of my children to be used in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets now known or hereafter devised. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing.

I understand and agree that these materials shall become the property of West Baptist Church and will not be returned.

I hereby hold harmless and release West Baptist Church from all liability, petitions, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.

If the person signing is under the age of consent, then this release must be signed by a parent or guardian as follows:

I hereby certify that I am the parent or guardian of named above, and do hereby give my consent without reservation to the foregoing on behalf of this individual.

Signature

Confirm Signature

Date

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