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By filling out and signing the online form below, I grant Countryside Feed, LLC full rights to use the image(s) of my child for fundraising, publicity or other purposes to help achieve the companies aims. This may include (but not limited to), the right to use them in their printed and online publicity, social media, press releases and funding applications

Waiver to Release Pictures 2020 Wall of Fame T-Shirt

*First Name of Person in Photo:

*Last Name of Person in Photo:

*Email (Parent/Guardian):

*Address:

*Phone Number:

*Date of Photo:

Today

mm/dd/yyyy

*Photo Upload:

*Is there a minor in the picture?:

Yes
No

Parent/Guardian Electronic Signature:

Only if you answered "yes" to the previous question

*Is this a Wall of Fame picture?:

Yes
No

T-shirt Size:

Only if you answered "yes" to the previous question

Security code: