Please complete the attached form and waiver entirely and submit along with payment. Emergency Contact information (Please provide us with 2 names) Name: ____________________________________________________________________________________ Home Phone: ______________________________ Cell Phone: ______________________________________ Name: ____________________________________________________________________________________ Home Phone: ______________________________ Cell Phone: ______________________________________ Giveaways and prizes. Choose Age Group 8 and Under 9 to 12 13 to 15 16 and Up Shirt Size: S M LG XL Skater First Name: ____________________________ Skater Last Name: ____________________________ Skater Age: _________ Sponsors: ___________________________________ Hometown/School: ___________________________ Skater Email: ________________________________ Address: ____________________________________ City: _______________________________________ State: _________________ Zip Code:___________
Photo/Video Release Form AUTHORIZATION TO USE PHOTOGRAPHS AND/OR AUDIO-VISUAL I, ___________________________________________, hereby authorize Michelle Reed Photography, Tim Shortell and Go Skateboarding Day Naples, to use, reproduce, and/or publish photographs and/or video that may pertain to me—including my image, likeness and/or voice without compensation. I understand that this material may be used in various publications, public affairs releases, recruitmentmaterials, broadcast public service advertising (PSAs) or for other related endeavors. This material may also appear on the Corporation's or project sponsor's Internet Web Page. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. Consequently, the Corporation or project sponsor may publish materials, use my name, photograph, and/or make reference to me in any manner that the Corporation or project sponsor deems appropriate in order to promote/publicize service opportunities. Description of Material (Photos/Audio-Visual):