Social Diversity Activist Form

Social Diversity Activist Form

Complete form below to become an SDC Activist!
Full Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Gender*
Date of Birth*

MonthDayYear
Date
School/Employer*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Languages*
Referred By
By signing below, you certify the following:
- I confirm that the above details are correct ot the best of my knowledge
- I hereby authorize any images or video footage taken of myself, in whole or in part, individually or in conjunction with other images and video footage, to be displayed on the Social Diversity for Children Foundation Website and other official channels, and to be used for media purposes including promotional presentations and marketing campaigns. I also authorize any media material created by myself within the Social Diversity for Children Foundation. I waive rights to privacy and compensation, which I may have in connection with such use of my name and likeness, including rights to be written copy that may be created in connection with video production, editing and promotion therewith.
- I acknowledge that $10 CAD will be charged as an annual activist fee, $18 CAD for two years, or $25 CAD for three years.
Signature*

Clear

Activist Fee*

Activist Fee - 1 Year($10.00CAD one-time payment)

Activist Fee - 2 Years($18.00CAD one-time payment)

Activist Fee - 3 Years($25.00CAD one-time payment)

Total $0.00CAD