Entry form & waiver

STORY POLES
in Downtown Orillia

A public art project by
STREETS ALIVE COLOUR FIN

Artist Name: _____________________________________________________________

Design Title: _____________________________________________________________

Sponsor: ________________________________________________________________

Draw your design on the back of this sheet OR on a separate sheet of paper.

***Waiver:

Artist:_____________________________________________________________

Phone: ___________________________ Email:___________________________

Address:______________________________________________________________________

I, the undersigned artist, agree to grant non-exclusive licence to the Orillia Streets Alive! organization to reproduce my artwork in any medium. I further license Streets Alive! to reuse, publish and republish photographs of me and/or my artwork in any medium. I further grant Streets Alive! the right to use my name, biography and likeness in any medium for the purpose of promoting the Orillia Streets Alive! organization only.

Signature:_______________________________________________ Date: _________________

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