Brother Andre's Ambassador

Name of Ambassador*

First Name

Last Name

Birth date*

Family's home parish

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Shirt Size - Adult Sizes Only

XS S M L XL 2XL

Parent / Guardian Information

Name of mother or legal guardian*

First Name

Last Name

Name of father or legal guardian

First Name

Last Name

Cell Phone Number (Mother)*

Cell Phone (Father)

Email (Mother)*

Email (Father)

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.*

YES, I authorize Move A Mountain Missions to use photos and videos NO, I do not authorize Move A Mountain Missions to use photos and videos

Signature

Signature: This signature is your authorization that all consents and statements completed above are true and valid.*

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Use your mouse or finger to draw your signature above.