Consent Form

The undersigned, being of legal capacity, hereby voluntarily consents to the taking of photographs/video of my person and to the use of my photograph/video, likeness and/or name and personal story in conjunction with information about Graceworks Lutheran Services and/or Bethany Village. Consent or denial of consent will not affect eligibility for services rendered to me. The undersigned hereby forever releases Graceworks Lutheran Services from any claims and waives any rights with respect to the use of my photograph, likeness and/or name and personal story in connection with any publication, republication, distribution, broadcast, sale or other use for news, trade or publicity purposes.

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Name (PRINTED)

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Signature

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Parent/Guardian signature (if required)

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Date

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Witness

Updated 01-26-06