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I, ___________________________________
(Parent or Legal Guardian if under 18 yrs. old)
do/do not (circle one) hereby authorize the Island Music Fiddle Club take or use photographs of
______________________________
(Name of Fiddle Club Participant)
for the sole purpose of using such photographs for Club business such as website, brochures, or local media
coverage and other such purposes as may be deemed appropriate to benefit the club and its membership. Such
purposes, however, shall not include any commercial endeavors.
____________________________________________________________________________________________
Name of Parent/Legal Guardian (if under 18 yrs.) or Name of member(if over 18 yrs. old) Telephone
Number
(Home/Cell)
_____________________________________________________________________________________________
Address
__________________________ ________________________ __________________________
City/Town State Zip Code
___________________________________________________________________________________________
Date E-MAIL
Members Instrument_________________________________________Grade Level (if in school)________________
School_____________________Music Teachers Name_______________________Private Teacher_____________
[ ] Fiddle Club Membership $50 ____$50_______
| Holiday 08 Registration Form and Photo & Promotion Authorization/Release Form |
