8th Annual Paint the Pony Purple

Step 1 — Select Tickets

If you have questions/problems filing out the form below or would prefer to purchase tickets over the phone, please call (800) 336-5843 ext. 119 or email jgleason@epilepsynj.org. Tickets will also be sold in person on March 23rd, at "Paint The Pony Purple" @ The Stone Pony in Asbury Park, NJ. Tickets are non refundable.

  Quantity Price Each Ticket Type
$50.00 VIP Admission
$25.00 General Admission
$10.00 50/50 Raffle Ticket
Additional Questions
Waiver

Photo Release Waiver

I do hereby consent and agree that The Family Resource Network (FRN), and all other affiliates/programs under The Family Resource Network, its employees and agents have the right to take photographs, videotape, or digital recordings of me/my child during my/my child's participation in the 8th Annual Paint the Pony Purple event to use in any and all media forms including; advertising, publications, website, internet and social media.  This (these) photograph(s) may be used indefinitely as part of the above mentioned program and may also be used to promote to educational or health professionals, referral sources, and/or the general public in print and/or electronic  format. I do hereby release to The Family Resource Network, and all other affiliates/programs under The Family Resource Network, its employees and agents, all rights to exhibit this work of myself/my child in print and electronic form for publicity or privately.

I further consent that my/my child's name and identity may be revealed therein or by descriptive text or commentary. I understand that I can withdraw my permission for future publication and that upon my written request, the photograph(s) will not be re-published for future circulation. This will not affect my/my child's  relationship with The Family Resource Network or staff in any way. I understand that I/my child will receive no financial or other reimbursement for recording, photographing or videotaping me/my child, either for initial or subsequent transmission or play back. If I want more information about the photograph(s), or if I have questions or concerns at any time, I can call or e-mail the Resource Development department at The Family Resource Network.

Clicking "I Agree" below means that I  have read and understand this form ; and that I am giving consent to be photographed during  my/my child's participation in the 8th Annual Paint the Pony Purple event thereby granting permission for the use of my/my child's photograph in any publication or advertising material (printed or electronic) of The Family Resource Network, and all other affiliates/programs under The Family Resource Network, its employees and agents. This consent also serves to waive all rights of privacy and compensation which me/my child may have in connection with the use of my/my child's photograph. 

I represent that I am at least 18 years of age, or am the parent or legal guardian of said child below and have read and understand the above statements, and will execute this agreement.


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