Work Force Development Application Form

School Name:

Student Name:

Student Email:

Business or Military Branch of services joining:

Street address for boots coupon or funds:

Demographics for reporting purposes

Age:

Sex:

Ethnicity:

Teacher providing Information:

MEDIA RELEASE FORM

I understand that I will be contacted by Zach Mitcham with HireSmart Cares, Inc. and I agree in advance to coordinate with Zach to be filmed, photographed and/or recorded, and that my likeness and/or voice may be used for a still photography marketing or video. I authorize Mark & Anne Lackey, HireSmart Cares, Inc. and The REI Resource, LLC dba HireSmart Companies, HireSmart Virtual Employees, & HireSmart VAs to make use of my name and/or image or likeness, video recorded as well as any photographs of me (collectively, the “Materials”) in marketing materials to be published in a variety of media, throughout the world, in perpetuity. Mark & Anne Lackey with HireSmart Cares, Inc. and The REI Resource LLC may copyright and license others to use the Materials. I acknowledge that Mark & Anne Lackey, HireSmart Cares, Inc. and The REI Resource, LLC dba HireSmart Companies, HireSmart Virtual Employees, & HireSmart VAs will rely on this permission potentially at substantial cost and hereby agree not to assert any claim of any nature whatsoever against anyone relating to the exercise of permissions granted hereunder. I understand I have no claim to potential earnings in the form of direct or indirect contributions and/or earnings to/of Mark & Anne Lackey, HireSmart Cares, Inc. and The REI Resource, LLC dba HireSmart Companies, HireSmart Virtual Employees, & HireSmart VAs.

Please Complete and sign:

Name:

City/State:

Phone:

Signature:

Date:

If Minor, Parent or Guardian - Please Complete and sign:

Name:

Email:

City/State:

Phone:

Signature:

Date:

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