Photo/Video Release Photo/Video Release I am a:*CamperStaff Member / ApplicantRetreat ParticipantI hereby give my consent and permission to Camp Coyote for the use of my likeness, name and voice for use in the manner that Camp Coyote, its employees or authorized agents may see fit. I hereby agree that all audio and video recordings of my likeness, name and voice produced by Camp Coyote, its contractors, agents, or employees, may be published, reproduced, exhibited, broadcast, through any media, and used by Camp Coyote to promote Camp Coyote without further consent from or payment to the undersigned who hereby forever releases and discharges Camp Coyote, its employees, licensees, agents, successors and assigns from any claim, actions, damages, demands whatsoever by any such use. I hereby waive the right to inspect or approve the finished photograph or advertising copy or printed matter that may be used in conjunction therewith or to the eventual use that it may be applied. I hereby release, discharge and agree to save harmless the photographer, his representatives, assigns, employees, or any person or persons, corporations or corporations acting under his authority, or any persons, corporations , for whom he might be acting, including any firm publishing and/or distributing the finished product, in whole or part, from and against any liability as a result of any normal use that may occur or be produced in the taking, processing, or reproduction of the finished product, it's publication or distribution of the same.Participant First Name*Participant Last Name*Street Address*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code*My typed name is intended to be my electronic signature. I am applying my electronic signature below to indicate my agreement to be bound by the preceding statements.Participant / Applicant Signature*Parent / Guardian Signature (if under 18)Date Time : HH MM AM PM This iframe contains the logic required to handle Ajax powered Gravity Forms.