Wine & Pottery Event Registration

WINE & Pottery Event registration  

at joe's crabshack in fairfax dec13th at 7pm-9pm

Name *
Second Guest's Name
Second Guest's Name
Birth Date (must be 21 years or older to participate) *
Birth Date (must be 21 years or older to participate)
Phone *
Address *
Payment Information
Cardholder's first and last name *
Cardholder's first and last name
Release of liability *
Release of Liability I release and hold harmless Jimmy Potters Studio, its owners and operators from any and all liability, claims, demands, and causes of action whatsoever, arising out of or related to any loss, damage, or injury, including death, that may be sustained by the participant and/or the undersigned, while in or upon the premises or any premises under the control and supervision of Jimmy Potters Studio its owners and operators or in route to or from any of said premises.
Photo release *
I grant to Jimmy Potters Studio, the right to take photographs of me and my work in connection with any Jimmy Potters Studio class. I authorize Jimmy Potters Studio, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Jimmy Potters Studio may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.