Adult

Your Name (required)

Address (required)

Address 2

City

State

Zip

Your email (required)

Your phone number (required)

I hereby authorize and consent to the use of images or videos of me, with or without my name, by Western Loudoun Community Church of Hillsboro, Virginia for purposes including but not limited to: promotional materials, printed publications, internet posts including social media, television, and other media sources.

I do this with full knowledge and consent and waive all claims for compensation for use or for damages. I release Western Loudoun Community Church, its officers, trustees, employees, and agents from liability for any claims by me or any third party in connection with the use of my image.

I agree with the above

Children (optional)

Your children (if any)

I, the legal parent/guardian, hereby authorize and consent to the use of images or videos of my child/children listed above, with or without their name(s), by Western Loudoun Community Church of Hillsboro, Virginia for purposes including but not limited to: promotional materials, printed publications, internet posts including social media, television, and other media sources.

I do this with full knowledge and consent and waive all claims for compensation for use or for damages. I release Western Loudoun Community Church, its officers, trustees, employees, and agents from liability for any claims by me or any third party in connection with the use of the image of my child/children listed above.

I agree with the above

Signature (required)
[signature signature cols:600 rows:200 background:#efefef]

Date (required)

Δ