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RELEASE OF MEDIA FORM

For Participation At: 

Muskoka Extreme Corporation

 

I, the undersigned, hereby consent to the use of my and/or my child’s photograph or likeness in any publication, videotape, pamphlet or promotion by Muskoka Extreme or other agencies which are promoting or furthering the mission of Muskoka Extreme. I understand that I will not receive separate compensation or consideration from Muskoka Extreme or anyone else for the permission granted in this Consent nor for the actual publication or use of their photograph or likeness. By signing this Consent, I understand I am releasing Muskoka Extreme from any and all liability that may occur as a direct or indirect result of my and/or my child's photograph, the release of my and/or my child's identity, or the public relations materials, including but not limited to the use of any quotations.

First Participant Name
First Name*
Last Name*
First Participant Age Acknowledgment*
First Participant Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant Signature*
Second Participant Name
First Name*
Last Name*
Participant Date of Birth*
Date of Birth
Third Participant Name
First Name*
Last Name*
Participant Date of Birth*
Date of Birth
Fourth Participant Name
First Name*
Last Name*
Participant Date of Birth*
Date of Birth
Fifth Participant Name
First Name*
Last Name*
Participant Date of Birth*
Date of Birth
Sixth Participant Name
First Name*
Last Name*
Participant Date of Birth*
Date of Birth
Seventh Participant Name
First Name*
Last Name*
Participant Date of Birth*
Date of Birth
Eighth Participant Name
First Name*
Last Name*
Participant Date of Birth*
Date of Birth
Ninth Participant Name
First Name*
Last Name*
Participant Date of Birth*
Date of Birth
Tenth Participant Name
First Name*
Last Name*
Participant Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
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*
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
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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