Cigarette Surfboard Film Screening Registration Form

The Cigarette Surfboard Film Screening

November 18th, 2025 3:30pm-6:00pm
Jenny Lind Veterans Memorial District - 300 W. Daphne Rd. Valley Springs, Ca
Celebrate the Great American Smokeout with a FREE film screening.

Meet the filmmakers + check out the “CIGGY BOARDS” + learn about local efforts against tobacco use and waste
General Information:

Must be signed by an adult over 18 years old.
Name*

First NameLast Name
Phone Number*
E-mail (If applicable)
We won't sell your information or spam you
Zip Code*

Street Address

Street Address Line 2

CityState / Province
Are you a youth or will you have a school aged youth with you?

YesNo
If yes, which grade(s)?
How did you hear about the film screening?

FlyerWord of mouthNewsletterOther
Provide any questions you would like asked during the Q&A session after the film:
Optional
Photograph Agreement

I hereby grant to Calaveras County Public Health (CCPH) the right to photograph me and to record my voice, performances, poses, actions, plays and appearances, and use my picture, photograph, silhouette and other reproductions of my physical likeness in connection with the production, The Cigarette Surfboard Film Screening (the “Production”).

I hereby grant to CCPH, its successors, assigns and licensees the perpetual right to use, as you may desire, all still and motion pictures and soundtrack recordings and records which you may make of me or of my voice, and the right to use my name or likeness in or in connection with the exhibition, advertising, exploiting, and/or publicizing of the Production.

I agree that I will not assert or maintain against CCPH, your successors, assigns and licensees, any claim, action, suit or demand of any kind or nature whatsoever, including but not limited to those grounded upon invasion of privacy, rights of publicity or other civil rights, or for any reason in connection with your authorized use of my physical likeness and sound in the Production as herein provided.

I hereby certify and represent that I am over 18 years of age (adults can sign on behalf of youth) and have read the foregoing and fully understand the meaning and effect thereof.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
I agree to be photographed.I do not want to photographed at this event.
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The Cigarette Surfboard Film Screening

Celebrate the Great American Smokeout with a FREE film screening.

General Information: