Child's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent Name *

First Name

Last Name

Phone

(###)

###

####

Release *

I grant OPP my permission to use any photographs or videos that I, the parent/guardian of the child above, provide to Oliver Patch Project (OPP) described for any legal use, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content. We respect and value your privacy; if photos of your child are used as part of any Oliver Patch Project Campaign, only their first name will be noted.