Clarion Loves Talent

"Clarion Loves Talent" Registration Form

DEADLINE: Postmarked by August 24, 2012

______INDIVIDUAL _____GROUP REGISTRATION

Individual/Main Contact Person:

Name: ___________________________________________ Age as of9/8/2012:_________________

Phone: _________________ Cell: _____________________ Email: ___________________________

Address: __________________________________________________

City: _________________________________ State: ______ Zip: _______________

IF you live outside of Clarion County, where do you work/attend school? _______________________

A brief description of your talent: ___________________________________________

_______________________________________________________________________

Name of Group: __________________________________________________

List ALL individuals in the group: _______________________________________________________________

__________________________________________________________________________________________

What song will you be singing or performing to: __________________________________________________

What equipment/props will you be using: ________________________________________________________

WAIVER: By signing this form we release the Clarion Area Chamber of Business and Industry, its staff, Board of Directors and members, all Sponsors for this event including, but not limited to, Clarion Hospital, Clarion University, and Woman’s Healthcare of Clarion from any and all liabilities whatsoever arising out of our participation in the "Clarion Loves Talent" event.

CONSENT: We have read and agree to the "Rules and Guidelines" for participation in "Clarion Loves Talent". We hereby consent to and authorize the reproduction and use of any and all photographs and videos taken for and during the "Clarion Loves Talent" competition as contestants. The Clarion Area Chamber of Business and Industry has permission to use photos and videos in the future on the "Clarion Loves Talent" website and the CACBI website or in publications.

There will be a sound system and power for electronic keyboards, etc. We have included the $5 registration fee, checks payable to Clarion Area Chamber of Business & Industry.

Signature: ________________________________________ Date: _______________

(Parent signature for all participants that are under the age of 18. Sign below if necessary)