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    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
    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
    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
  • OK Agreed and accepted by is required
  • OK Name is required
  • OK Business Name is required
  • OK Your Title is required
  • OK Social Media Handles is required
  • OK Address is required
  • OK City is required
  • OK State is required
  • OK Zip Code is required
  • OK Phone is required
  • I am submitting this form as an individual

    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

    OK I am signing this form as a representative of a group, and have full authority to grant release for this group is required
  • OK Name of group is required
  • I am over the age of eighteen years

    OK I am over the age of eighteen years is required

Parental Consent

  • OK Name of Applicant’s Parent/Guardian is required
  • OK Address of Applicant's Parent/Guardian is required
  • OK City is required
  • OK State is required
  • OK Zip Code is required
  • OK Phone is required
    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