Media Release Form Whose consent does this media release apply to? Select who this media release applies to: yourself, your child/children, or both. * MyselfDependent(s)Both Self and Dependent(s) Adult Information Name * Name First Name First Name Last Name Last Name Phone * Email * Address * Address Address Address City City State/Province Florida AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Date of Birth * Age Minor Information A minor under 20 requires a parent or legal guardian’s consent for the media release. Minor Name Minor Name First Name First Name Last Name Last Name Minor Date of Birth Minor Age Relationship DaughterSonWardSibling (Sister/Brother)Partner (if applicable) Parent / Guardian Information Same as AboveEnter new details Parent/Guardian Phone Parent/Guardian Email Parent/Guardian Address Parent/Guardian Address Parent/Guardian Address Parent/Guardian Address City City State/Province Florida AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal plus1 Add minus1 Remove Acknowledgment I acknowledge and grant permission to, Anchor Rock Building Materials LLC, Pop’s Nursery, El Eden Management LLC and any of their subsidiaries, hereinafter known as the "Media" to use my image (photographs ando/r video) for use in Media publications including: Videos Email Blasts Recruiting Brochures Newsletters Magazines General Publications Website and/or Affiliates Social Media and any other 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 20 years of age or older and competent to contract in my own name and/or I am the parent or legal guardian of the above-named child or children, if applicable. I have read this release before signing below and fully understand its contents, meaning, and impact. I understand that I may address any specific questions regarding this release by submitting them in writing prior to signing, and my failure to do so will be interpreted as free and knowledgeable acceptance of the terms of this release. Consent * I have read and understand the waiver agreement above and by signing this document, I hereby agree and confirm that I will abide by it. Signature * signature keyboard Clear Date * Submit Start Over If you are human, leave this field blank. We Have The Materials That You Need Materials Soil View more Materials Sand View more Materials Stones View more Materials Limestone View more
