Name of Ambassador*
Birth date*
Shirt Size - Adult Sizes Only

Parent / Guardian Information

Name of mother or legal guardian*
Name of father or legal guardian

Photographic Release

I grant and convey unto Move A Mountain Missions all right, title, and interest in any and all photographic images and video or audio recordings made by Move A Mountain Missions and Brother Andre's Cafe, including but not limited to, any royalties, proceeds or other benefits derived from such photographs or recording.*


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