Moderator Information Form Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *AddressCity, State ZipCommentsIn consideration of the opportunity to appear on an audio/videotape depicting various aspects of the presentations and activities of the 2023 USA/Canada Lions Leadership Forum, the undersigned hereby waives any and all rights and interests in said audio/videotapes, relinquishing said rights to the 2023 USA/Canada Lions Leadership Forum, including, but not limited to, the right to receive any and all proceeds derived from the sale of said tapes for educational and promotional purposes.ELECTRONIC SIGNATURE: *Clear SignatureIMPORTANT NOTICE: Typing your name in the box above will constitute your electronic signature.Date *Submit
