Sponsorship Form

Camper’s Name * Date of birth Age during camp How many years has your camper attended camp? Name of person or organization sponsoring your camper Camper’s shirt size: Email * Address including city, state & zip: Parent/guardians names cell Phone work Phone Emergency contact cell Phone work Phone relationship By choosing yes to this release form as marked below, I authorize C.O, Mollenhour Conservation Camp, to use the following personal information of my child: (1) My child’s picture – including photographic, motion picture, and electronic (video) images. (2) My child’s voice – including sound and video recordings. I hereby grant C.O. Mollenhour, its subsidiaries, licensees, successors, and assigns, the right to use, publish, and reproduce, for all other purposes, my child’s name, pictures of my child in film or electronic (video) form, sound and video recordings of my child’s voice, and printed and electronic copy of my voice, and printed and electronic copy of the information described in sections (1) and (2) above in any and all media, including, without limitation, cable and broadcast television and the internet, and for exhibition, distribution, promotion, advertising, sale, press conferences, meetings, hearings, educational conferences, and in brochures and other print media. This permission extends to all languages, media, formats, and markets known or herby devised. This permission shall continue forever unless I revoke the permission in writing. I further grant C.O. Mollenhour all right, title, and interest that I or my child may have in all finished pictures, negatives, reproductions, and copies of the original print, and further grant C.O. Mollenhour the right to give, sell, transfer, and exhibit the print in copies or facsimiles thereof, for marketing, communications, or advertising purposes, as it deems fit. I also waive any right to inspect or approve finished photographs, audio, video, multimedia, or advertising recordings and copy or printed matter or computer-generated scanned image and other electronic media that may be used in conjunction there with or to approve the eventual use that it might be applied. I acknowledge that I have read the foregoing and I fully understand the contents. Will your camper be taking medications during camp?: