Midrealm Squires Website Consent to Publish and Release form

 Please copy the information below (between the ***'s), and paste it into the email link after you click on it. Answer the questions, attach any graphics, and then send the email off to complete your release and new site addition. Please let me know what contact information you want displayed on your page.

All information preceded by an asterisk is required information.

Email the webmaster - if this does not open your email client, send the email to tomnadra [at} yahoo (dot] com, with the subject line "Midrealm Squire Page Release"

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I do hereby grant permission to publish my contact information and photograph on any page hosted by the domain midrealm.org for the Purpose of the SCA.

 

* Real Name:
* SCA Name:
* Address:

* City, State, ZIP:
* Phone Number(s):
* Email address(s):
* Date:

Knight:
Date Squired:
Region/Household Affiliation
Awards:
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