Release - please print, complete, sign and mail to Siracusa Moving and Storage
I, the undersigned, authorize the Siracusa Moving and Storage to use any original material submitted by my child through the Siracusa Moving and Storage Photo Submission section on Siracusa Moving and Storage, now and in the future without further notice or compensation, and agree that such material will be freely available for download and distribution.
Name: __________________________________________
Child's Name ___________________________________
Child's name as you would like it to appear on the website
__________________________________________________
Permission to use Child's Last Name Yes ___ No ___
Permission to use Child's Photo if provided Yes ___ No ___
Adult Signature ________________________________________________________
Parent or Guardian's Signature_________________________________________
Print Name _________________________________________________________
Address__________________________________________________
__________________________________________________
__________________________________________________
Date ______________________________
Please send the SIGNED form to the following address
Siracusa Moving & Storage
Phone Number: (800) 222-1399 (860) 225-9144
250 Commerce Circle
New Britain, Connecticut 06051
Email: info@move-us.com
|
|
