Countryside Feed Wall of Fame

Waiver to Release Pictures

*First Name of Person in Photo:

*Last Name of Person in Photo:

*Email (Parent/Guardian):

*Address:

*Phone Number:

*Date of Photo:

mm/dd/yyyy

*Photo Upload

Please select a file

*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