Participant's Name *

First Name

Last Name

Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

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Date

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YYYY

MEDIA RELEASE *

I agree to allow my name, photograph, voice, image, and information to be used by the Program for use in the Program's publications, promotion materials, website, and social media sites without compensation and without prior notice. I hold the Program harmless from any liability stemming from the use of the my name, photograph, voice, image, or information.

I give permission for The Ohmapi Nature Project to use images of myself in program publications and media.

I do not give The Ohmapi Nature Project permission to use images of myself in program publications and media.

Particpant''s Name *

First Name

Last Name

Date *

MM

DD

YYYY