Name

First Name

Last Name

Phone *

(###)

###

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Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

Please list the phone number for your emergency contact

(###)

###

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Photo and Video Release *

By checking "I agree" below, I grant Tony's Place, its representatives, employees, and agents the right to take, use, and publish photographs and/or video footage of me in any manner or medium, including but not limited to print, digital, and online formats. This permission extends to the use of these images and/or footage for promotional, educational, and advertising purposes, including but not limited to brochures, websites, social media, and other materials. I understand that these images and/or footage may be used without further notice or compensation. I also acknowledge that the images and/or footage may be used in various forms and that Tony's Place is not obligated to use them in any particular way. I release Tony's Place from any claims, demands, or liabilities arising out of or in connection with the use of these images and/or footage. This release is effective from the date this form was submitted and will remain in effect indefinitely unless revoked in writing.

I agree

I do not agree