Media Release/Medical Waiver & Authorization Form

I understand that I may be included in media coverage of the Red River Zoo.

I grant the Red River Zoo permission to use my name, image, voice appearance and likeness for stories or advertisements that may be solicited on behalf of the Red River Zoo.

This may include but is not limited to, print advertising, public service announcements, promotional videos, etc. The Red River Zoo will be the sole owner of the rights to use, or not use, my likeness in promotions.

I understand I will not be eligible for any compensation related to the production and use of my name or likeness in promotional or advertising materials.

If I do not wish to be photographed or interviewed for news or promotional coverage, I understand it is my responsibility to remove myself from situations where my wishes might be violated.

I agree to waive my rights to hold this non-profit or it's associates responsible for any liability, loss or damage that occurs from my participation in any promotional activities.

I have read, understand and will comply with this agreement. Parent/Guardian Electronic Signature:*

Date*

MonthDayYear

First Participant's Name*

First NameLast Name

Second Participant's Name

First NameLast Name

Third Participant's Name

First NameLast Name

Fourth Participant's Name

First NameLast Name

Fifth Participant's Name

First NameLast Name

Parent/Legal Guardian*

First NameLast Name

Email*

example@example.com

Home Phone*

Area CodePhone Number

Work Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Emergency Contact Person*

First NameLast Name

Home Phone*

Area CodePhone Number

Work Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

In case of accident or illness, the Red River Zoo has my authorization to secure medical attention from physicians, nurses, hospitals and clinics for my child. Physician's Name*

First NameLast Name

Clinic Name*

Health Insurance Company*

Allergies (food, animal, etc.)

Up-to-date tetanus vaccination? *

YesNo

Date*

MonthDayYear

Program Release:

I hereby for myself, my children , my heirs and executors, waive and release any and all rights and claims for damages that I may have at any time against the Red River Zoo or Red River Zoological Society, their agents or representatives; for any injury or damages that may be suffered by me or my child in connection with my association or entry into the Red River Zoo, Junior Zookeeper Program, or other activities sponsored by the Red River Zoo or Red River Zoological Society.

I understand that participation in programs at the zoo involves some contact with animals and as such carries with it the potential for risk of injury. In case of injury or illness, the Red River Zoo has my authorization to secure medical attention from physicians, nurse, hospitals, and clinics for my child if I am not present.

Parent/Guardian Electronic Signature*

Media Release & Medical Authorization Waiver