Minorʻs Name *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact Phone *

(###)

###

####

MEDIA RELEASE *

Heleloa Media Club and associated affiliates (club members, instructors, chaperones, business partners) have my permission to create and use digital or print media of my child and child’s name, work, voice, or likeness.

Yes

Minorʻs Signature *

First Name

Last Name

Parent/Guardianʻs Signature *

First Name

Last Name

Date *

MM

DD

YYYY