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Interested in becoming one of our mentors?

MENTOR

Interested but need more information.

MEDIA RELEASE FORM

PERSONAL INFORMATION

First name

Last name

Address

Phone

Birthday

Month

Day

Year

I grant permission to WeSource: The Village Connection (hereinafter referred to as "WeSource") to use my image (photographs and/or video) for use in WeSource publications, including but not limited to:

Please provide a list of under-aged attendees that you authorize for publication (if applicable).

I hereby waive any right to inspect or approve the finished photographs, videos, 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. I also waive any right to royalties or other compensation arising from or related to the use of my image or likeness.

ACKNOWLEDGEMENT

Please initial the paragraph that applies to your current situation:

I am the parent or legal guardian of the below-named child. I have read this release before signing below, and I fully understand its contents, meaning, and impact. I understand that I am free to address specific questions regarding this release by submitting those questions in writing before signing. I agree that my failure to do so will be interpreted as free and knowledgeable acceptance of the terms of this release.

Initials