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MEDIA RELEASE FORM


By signing this waiver, I grant permission to Boop Society of Central Texas and Reuben L Atkins (further known in this form and on social media as Queeries and More) to use my image (photographs and/or video) for use in advertisement, promotional material, and social media, hereinafter known as the “Media”. By signing this waiver, I acknowledge that:


I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.


I am 18 years of age or older and I am competent to contract in my own name.


I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing or verbally, in person, prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.



Signature:




Date: December 11, 2024

Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
First Participant's Extra Contact Information (optional)

Preferred Name

Phone Number

Social Media Profile Link to Tag You In

Description of gear and wear while at mosh. *
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Extra Contact Information (optional)

Preferred Name

Phone Number

Social Media Profile Link to Tag You In

Description of gear and wear while at mosh. *
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Extra Contact Information (optional)

Preferred Name

Phone Number

Social Media Profile Link to Tag You In

Description of gear and wear while at mosh. *
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Extra Contact Information (optional)

Preferred Name

Phone Number

Social Media Profile Link to Tag You In

Description of gear and wear while at mosh. *
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Extra Contact Information (optional)

Preferred Name

Phone Number

Social Media Profile Link to Tag You In

Description of gear and wear while at mosh. *
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Extra Contact Information (optional)

Preferred Name

Phone Number

Social Media Profile Link to Tag You In

Description of gear and wear while at mosh. *
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Extra Contact Information (optional)

Preferred Name

Phone Number

Social Media Profile Link to Tag You In

Description of gear and wear while at mosh. *
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Extra Contact Information (optional)

Preferred Name

Phone Number

Social Media Profile Link to Tag You In

Description of gear and wear while at mosh. *
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Extra Contact Information (optional)

Preferred Name

Phone Number

Social Media Profile Link to Tag You In

Description of gear and wear while at mosh. *
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Extra Contact Information (optional)

Preferred Name

Phone Number

Social Media Profile Link to Tag You In

Description of gear and wear while at mosh. *
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Extra Contact Information (optional)

Preferred Name

Phone Number

Social Media Profile Link to Tag You In

Description of gear and wear while at mosh. *
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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