Free photo release form 49
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West Linn-Wilsonville Youth Basketball Association
Consent and Photo Release Form
Participant Name __________________________________________________________________________
Address __________________________________________________________________________________
City
_______________________________________
State ___________
Zip ______________
School ________________________ Grade ________ Gender ________ Date of Birth ____/_____/______
Home Phone ______________________________
Participant’s Cell Phone ________________________
List any allergies, medical conditions or specific needs _____________________________________________
__________________________________________________________________________________________
Parent/Guardian (1) Name ___________________________________________________________________
Home Phone ____________________ Work Phone _____________________ Cell ____________________
Email Address __________________________________________________________________________