BC NATIVE WOMENS ASSOCIATION

MEMBERSHIP FORM

Full Name:

Date of Birth (Optional):

Phone Number:

Email:

Mailing Address:

City:

Postal Code:

Please check all that are appropriate:
o
o
o

First Nations
Inuit
Mtis

o
o

Youth (between the age of 14-30)

Elder

o
o
o
o

Status
Non status
On Reserve
Off Reserve

Adult Media Release (19 years and older)
I hereby consent to the use of my images of the photographs, video or electronic reproduction forms or
materials produced by BC Native Womens Association (BCNWA) and all departments of BCNWA. I release
BCNWA, Its department, staff, and photographer from liability for any violation of any personal propriety right in
connection with such use. I waive all rights to royalties or other compensation arising from, or related to the use
of media images.
I understand that these reproductions may be used in the production of materials used to promote
BCNWA programs and departments.
I also understand that the choice, of which reproduction is to be used, if any, is at BCNWAs discretion. I
also understand that I do not have copyrights to any photographs, video or electronic reproductions made by
BCNWA.

I hereby authorize the verification of information provided on this form.

Signature_____________________________________________


Date _________________________________________________

144 Briar Ave | Kamloops, BC | V2B 1C1 | Phone: 250-554-4556 | Fax: 250-554-4573