Name *

First Name

Last Name

Phone *

(###)

###

####

Media Release *

Do you authorize The Macoupin Art Collective to photograph, take video footage, and/or make electronic sound recordings of you, and to use such photographic or electronic reproductions of you for any purpose, including, but not limited to educational and other public media (such as Facebook advertisements and marketing materials)? Note that you may be identifiable from such photographic or electronic reproduction. This form serves as your electronic signature as an individual, or as a representative of a group for which you have full authority to sign such a release. Opting out of this media release will in no way prevent/preclude you from participating in activities at The Macoupin Art Collective.This form serves as your electronic signature as an individual, or as a representative of a group for which you have full authority to sign such a release. Opting out of this media release will in no way prevent/preclude you from participating in activities at The Macoupin Art Collective.

Yes

No

Policies *

Please certify that you have read and understand our non-discrimination, refund, and privacy policies (link at the bottom of this page or under the ‘About Us’ heading in the page menu).

Yes

Covid Policy *

We need to make sure you read our Covid Policy. We also need to make sure you will comply with this policy. Please view it here: https://macart.org/policies

I have read the policy and I will comply