MADD Texas Teen Influencer Application
This is a group of substance free teens making an impact.
Student Name:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student E-mail:
example@example.com
Name of Student's School:
City of Student's School:
Student's Grade:
Student's Age:
example@example.com
Parent Name:
First Name
Last Name
Parent's Email
example@example.com
Parent Cell Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Instagram Username:
Twitter Handle:
Tik Tok Username:
WhatsApp Profile Name:
Snapchat Username:
Why is it important to you to not drink before you're 21?
What school/volunteer or extracurricular activities are you involved in? Are you currently employed?
Why should you be considered to participate in the MADD Teen Influencer Group? What skills and talents do you possess?
What do you hope to gain as a Teen Influencer?
Applicant must submit a headshot and a short bio to be considered. If selected, the headshot and bio will be used to introduce you on MADD Texas social media. Upload Photo here:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
CONSENT FOR PHOTO/VIDEO RELEASE
By signing in the box below, I grant Mothers Against Drunk Driving permission to use images (photographs or videos) of my child who is listed on this consent form. I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image. I am the parent or legal guardian of the below named child. I have read this release before clicking below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release. I grant Mothers Against Drunk Driving permission to use images or video for promotional purposes. *
Consent For Photo/Videos Release
I consent
I do not consent
Student Applicant Signature:
Parent/Guardian Signature:
Submit
Should be Empty: