a documentary film about 30 years of Houston's burn culture

did we film you?

MODEL RELEASE

First Name *

Last Name *

Burner Name

or nickname

Date of birth *

Phone *

Email *

State

City

Social Media

Facebook
Instagram
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Postal Code

Selfie (so we know who you are) *

your photo

PNG, GIF, JPEG or JPG

Signature *

Clear

I am giving permission to use footage of me for the film and promotional use *

YES, I agree to be a part of this film project.

By checking this box, I consent to receive non-marketing text messages from Burn Houston about Updates about the film project, preview showings exclusively for those that have been apart of the project.. (most likely you if your filling this out). Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from Burn Houston at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.