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Participant Enrollment

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(mm/dd/yyyy)
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First Name
Last Name

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country



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Activities Interest
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Publicity release

I hereby authorize BOAA to record and photograph my image and/or voice in any promotional materials and/or media pieces relating to its program.  I understand and agree that these audio, video, film and/or print images may be edited, distributed, reproduced, broadcast and/or reformatted in any form and manner without payment of fees in perpetuity. I understand that permission for media release is voluntary and in no way affects my ability to participate in BOAA.

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