ICCL INDIAN CULTURAL COMMUNITY LAOIS
ICCL MEMBERSHIP FORM
Please include details of all family members
(Please mention the age ONLY if under 18 years old)
Members
*
Address
*
Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address in India (Optional)
Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Details
Mobile
*
Landline
E-mail
*
example@example.com
Emergency Contact Details in India (Optional)
Mobile
Landline
E-mail
example@example.com
Name of an applicant
Signature
Date
/
Month
/
Day
Year
Date
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Photo / Video Consent Form
I give permission to take photographs and / or video and grant full rights to use the images resulting from the photography/video filming, and any reproductions or adaptations of the images for online sharing among ICCL members, fundraising, publicity or other purposes to help achieve the group’s aims. This might include (but is not limited to), the right to use them in their printed and online social media such as whatsapp & face book, I also give permission to take photos/videos of my child for above mentioned purpose
Name
Signature
Date
/
Month
/
Day
Year
Date
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