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Vancouver Island Awareness Project: Photo & Video Release

I, , hereby

agree

disagree

to have my name, photo and location released to

Cerebral Palsy Association of British Columbia, located in Vancouver, BC,

AND

Intercultural Strategies, located in Richmond, BC,

for marketing purposes.

My information:

Phone:
Email:
City:
CPABC Member:
Are you participating in the Vancouver Island awareness project?:

I am 18 years or older.

I am under 18 years and will have my parent / guardian sign this form.

Parent / Guardian Name:

By signing below, I certify all information is true and correct to the best of my knowledge.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

September 27, 2020 10:47 am PST

Vancouver Island Awareness Project: Photo & Video Release Uploaded by Denzil Muncherji - programs@bccerebralpalsy.com IP 62.197.154.25

August 9, 2024 11:45 am PST

CPABC Info - info@bccerebralpalsy.com added by Denzil Muncherji - programs@bccerebralpalsy.com as a CC'd Recipient Ip: 23.16.205.224