Talent Competition - Group Entry

Participant Information

Group Name/Performance Name*

Number of Group Members*

Names*

Age*

Talent Category

Video Link

Parent/Guardian Information

Parent/Guardian Name*

Phone Number*

Email*

Mailing Address

Social Media Username

Do you have a social media (Facebook or Instagram) that you would like us to tag?

Model Release and Authorization to Video/Photograph

As the child's parent/guardian, I hereby grant a license to The Independent Health Foundation and their agents, including any advertising agencies, to use and to license others to use the students name, recorded voice, image, picture or likeness in any live or recorded audio, video or photographic display or other transmission for purposes of promotion and publicity in connection with the First Night Buffalo program and hereby waive any rights of compensation or ownership thereto. I certify that I am the parent or legal guardian of the listed participant and that I have the authority to grant this permission to participate in the contest on behalf of the participant.

I HAVE READ, AND I UNDERSTAND, AND I VOLUNTARILY SIGN THIS MODEL RELEASE AND AUTHORIZATION TO VIDEO/PHOTOGRAPH.

Authorization for Photograph/Video*

Yes, my child can be photographed

Parent/Guardian Name*

Parent/Guardian Signature*

Date*

Talent Competition - Group Entry

First Night Buffalo

Event Info

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