Membership and Media Release Form Name * First Name Last Name Email * Phone * (###) ### #### Preferred Instrument / Secondary Instrument * Address * (required by society by-laws) Address 1 Address 2 City State/Province Zip/Postal Code Country School * If you are a student Age * if you are 19 or under Are there medical conditions or allergies you would like the board to know about? (e.g. anything that may require use of an Epi-pen, insulin, or emergency medication?) Media Release I hereby grant or deny the Fraser Valley Wind Ensemble (FVWE) Society permission to use my image, as indicated by my selection below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, recordings, videos, or other media of me for use in materials including, but not limited to, printed materials such as brochures and newsletters, videos, the FVWE Society website, and social media outlets such as Facebook and Twitter. * Yes No FVWE Phone Directory I grant the FVWE Society permission to share my phone number, e-mail, and address to members of the ensemble for purposes of communication regarding rehearsals and concerts * Yes No Today's Date * MM DD YYYY Digital Signature * (type your name as indication of signature) Thank you!
