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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
AK - Alaska
AL - Alabama
AR - Arkansas
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
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
AK - Alaska
AL - Alabama
AR - Arkansas
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE - Delaware
FL - Florida
GA - Georgia
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
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