WEST COUNTY HEALTH CENTERS, INC.

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Presentation transcript:

WEST COUNTY HEALTH CENTERS, INC. Example Release Form WEST COUNTY HEALTH CENTERS, INC. Occidental Area Health Center • Russian River Health Center Sebastopol Community Health Center Gravenstein Community Health Center Forestville Teen Clinic • Forestville Wellness Center Russian River Dental Clinic • Mental Health Services STANDARD RELEASE FORM I hereby consent to any recording of myself on videotape, film, audio tape, paper, digital medium, or otherwise, by West County Health Centers (WCHC). I authorize the use of such material for any proper and legitimate educational or commercial purposes by WCHC. I acknowledge WCHC’s ownership of the material and further agree that you may use my name, likeness and biography for the purpose of promoting the program. I warrant and represent that all material furnished by me is my own or for which I have full authority for such purposes. Signature Date Name (please print) Street Address City, State, Zip Telephone Email Address West County Health Centers, Inc. P.O. Box 1449, Guerneville, CA 95446 (707) 869-5977 www.wchealth.org