Consent Form

UPDATED: 6/2022

>>>> USE LINKS AT BOTTOM OF PAGE TO DOWNLOAD PRINTABLE VERSION <<<<< (5/2021)

PREVIEW: (7/2014)

Directions: Print, complete blanks, check any boxes that apply, add new boxes if not listed, sign, date, photocopy for your own records ,attach enclosures if available, and mail to: PO box 92,Celoron, NY 14720.

Or you may scan and email to: spunkyproductions@mail.com [ Heading Subject: Consent Form: (musicians name)]

I consent to my (son/daughter/husband/wife's)________, release of information and nomination for the Musicians Memorial Local Legends of Music Fund's "Wall of Fame", hereby named as__________________________ (be specific with nicknames in quotes, and middle initial or surnames, specify: jr. sr. II or III) .He/she played/and performed in the band known as __________________________________________. (List all if possible)

His/her name will be promoted and printed in publications, and on t-shirts, flyers and other items regarding the Musicians Memorial including, but not limited to, all fundraisers ,promotions, broadcasts, publications utilized such as Niteline Magazine, WRFA broadcasts, marketing strategies, etc. for the sole purpose of raising awareness of his/her legacy and to raise funds for the Chautauqua County Local Legends of Music Memorial Fund. A plaque will be created in his/her honor. Information which is already public will be accessed to represent his/her webpage where stories can be shared and viewed by others on Facebook and the internet.

___ I am interested in writing up a bio/personal story for him/her.

___ I would like to submit musical works compilation to be included in the playlist/line-up at the Memorial Show. (copy of his/her CD)

___ I would like to submit photos/videos to be presented at the Memorial Show.

___ I would personally like to speak at the Memorial show on his/her behalf.

___ My band would like to volunteer to play at the Memorial show.

Sincerely:

____________________________________________ DATE___________________

*Required (Please enclose a copy of the musicians printed public obituary. Thanks!)

List all band members below if possible:

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Nominee Consent Form 2022 pdf.pdf
Nominee Consent Form 2022.odt