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Please remit all checks to:
Rice Lake Area Chamber of Commerce
37 S Main St, Rice Lake, WI 54868-2299

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Consent and Release Forms

Date*

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Rice Lake Chamber of Commerce, its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet).

This consent includes, but is not limited to: (select where applicable)*

(a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;
(b) Permission to use my name; and
(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.

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The below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child.

Signature of Parent or Legal Guardian:

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Arrowhead Family Dental

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Rice Lake Chamber of Commerce - Membership 2019

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Arrowhead Family Dental

Rice Lake Chamber Membership

Rice Lake Chamber of Commerce - Membership 2019

Check Payment

Credit Card Payment

Consent and Release Forms