Coffee, Tea and Autism Support Group with the Autism Society of Mahoning Valley
Thursday, December 15, 2022
9:30am-10:30am
Cracker Barrel - 5600 Patriot Blvd, Austintown (80 & 46 intersection)

Thank you to our facilitators, Kesha Lampley, LSW and Robin Suzelis, ASMV Director for hosting.

* Required Field

*Parent's or Caregiver's Name(s):
*Address:
*City:
*State:
*Postal Code:
*Cell Phone Number:
*Email Address:
*Person with Autism Name:
*Person with Autism Date of Birth:
I give permission and consent to allow photographs to be taken during Autism Society of Mahoning Valley activities. I further give permission and consent that any such photographs may be published and used by Autism Society of Mahoning Valley and its agents, to illustrate and promote its programming and fundraising efforts.

Furthermore, I grant the Autism Society of Mahoning Valley, its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize the Autism Society of Mahoning Valley, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Autism Society of Mahoning Valley may use such photographs of my family with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I have read and understand the above:
By Submitting this form, I am registering for the event and accepting the terms of this release form.