AP | Program Participant Application - Adult

I understand that in the event medical intervention is needed, every attempt will be made to contact the person(s) that I have listed above on this registration. if my contacts cannot be reached, I hereby give permission to the physician or dentist, selected by the leaders at the "Friends of" location at which I am participating, to secure treatment for me as deemed medically necessary. My signature acknowledges permission as stated above.

I authorize and grant Attack Poverty and the "Friends of" location, at which I am participating, the right to use, publish, and copyright my image (including audio, moving image, or photograph) for educational programs, web sites, and for the purpose of marketing and promotions. This release is effective from the date of signature. if I do not wish to be photographed or interviewed for news or promotional coverage, I will remove myself from situations where my wishes may be violated. I agree to waive my rights to hold Attack Poverty, their officers, agents, and employees responsible for any liability, loss, or damage that occurs from my participation in any promotional activities.

I certify that this application was completed by me and that all of the information on this application is true and correct to the best of my knowledge. I understand that this application is not valid without my signature.