Contra Costa Mineral & Gem Society

Photo/Video Release Form

I give permission for my name, likeness and biographical material to be used solely for the purposes of CCM&GS related promotional and educational publications and waive any rights of compensation or ownership thereto.

Name (please print): _______________________________________________

Signature: ______________________________________ Date: ___________

Address: ________________________________________________________

City, State, Zip: ___________________________________________________

Phone: _____________________________

Email: ______________________________

Member of CCM&GS ____, Other ____

Under 18 years of age? Please continue….

As parent/guardian of the above minor, I give my permission for him/her to participate in the audio/video activity under the terms above.

Name (please print)
of parent/guardian: ________________________________________________

Signature: ______________________________________ Date: ___________