Mommy and Me Mentorship Registration Form

PHOTO/VIDEO RELEASE FORM

www.neeshspeaks.com - 7402 Front Street,
Cheltenham, Pennsylvania 19012

This form is for the legal release of your photos/videos.
For minors, please let a parent/guardian sign it.

This form is to authorize Neesh Speaks, LLC to publish photos/videos that
are taken/recorded of the following person/s
I hereby authorize Neesh Speaks, LLC to publish photos/videos that are
taken/recorded of me during
Mommy and Me Mentorship Program for the company's
online and print marketing materials.

I am aware that this form releases the company from any liabilities or claims.
I fully understand the terms and conditions under this agreement.
PARENT/GUARDIAN NAME: First Name* Last Name*
PARENT/ GUARDIAN SIGNATURE*

Clear
DATE:*
"AT THE BOTTOM OF EDUCATION, AT THE BOTTOM OF POLITICS, EVEN AT THE
BOTTOM OF RELIGION, THERE MUST BE FOR OUR RACE ECONOMIC INDEPENDENCE"
- BOOKER T. WASHINGTON

PHOTO/VIDEO RELEASE FORM