Media Release Form

- I, the undersigned, hereby authorize Fidelity Bank to photograph me, take motion pictures of me, take video footage of me, and/or make electronic sound recordings of me (herein referred to as photographic or electronic reproductions).
OK I, the undersigned, hereby authorize Fidelity Bank to photograph me, take motion pictures of me, take video footage of me, and/or make electronic sound recordings of me (herein referred to as photographic or electronic reproductions). is required
- I authorize the use of any such photographic or electronic reproductions of me for any purpose, including, but not limited to educational and other public media as may be deemed appropriate by Fidelity Bank (I understand that I may be identifiable from such photographic or electronic reproduction).
OK I authorize the use of any such photographic or electronic reproductions of me for any purpose, including, but not limited to educational and other public media as may be deemed appropriate by Fidelity Bank (I understand that I may be identifiable from such photographic or electronic reproduction). is required
- I understand that I waive the right of approval for the final form for which these images and recordings are used and that I will not receive financial compensation for the use of the materials. I also agree to hold Fidelity Bank harmless for liability of any nature.
OK I understand that I waive the right of approval for the final form for which these images and recordings are used and that I will not receive financial compensation for the use of the materials. I also agree to hold Fidelity Bank harmless for liability of any nature. is required
Agreed and accepted by
OK Agreed and accepted by is required
Name
OK Name is required
Business Name
OK Business Name is required
Your Title
OK Your Title is required
Social Media Handles
OK Social Media Handles is required
Address
OK Address is required
City
OK City is required
State
OK State is required
Zip Code
OK Zip Code is required
Phone
OK Phone is required
I am submitting this form as an individual
- No
- Yes
OK I am submitting this form as an individual is required
I am signing this form as a representative of a group, and have full authority to grant release for this group
- No
- Yes
OK I am signing this form as a representative of a group, and have full authority to grant release for this group is required
Name of group
OK Name of group is required
I am over the age of eighteen years
- No
- Yes
OK I am over the age of eighteen years is required

Parental Consent

Name of Applicant’s Parent/Guardian
OK Name of Applicant’s Parent/Guardian is required
Address of Applicant's Parent/Guardian
OK Address of Applicant's Parent/Guardian is required
City
OK City is required
State
OK State is required
Zip Code
OK Zip Code is required
Phone
OK Phone is required
- I certify that I am the parent or guardian of the individual above, a minor under the age of eighteen years. I hereby agree to assume legal responsibility for his/her authorizations referred to in this Media Release.
OK I certify that I am the parent or guardian of the individual above, a minor under the age of eighteen years. I hereby agree to assume legal responsibility for his/her authorizations referred to in this Media Release. is required

OK is required

Online Banking

Online Banking

I am submitting this form as an individual

I am signing this form as a representative of a group, and have full authority to grant release for this group

I am over the age of eighteen years

Parental Consent