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Testimonial Consent Form

Testimonial Consent Form
*Indicates required information

I consent to being contacted by a representative of McLaren-Central Michigan's Marketing Department for the purpose of featuring my experience at McLaren-Central Michigan as a testimonial advertisement.  I understand that my name, photo, and city of residence may be used for testimonial advertisement in McLaren-Central Michigan promotional material. Promotional material includes the McLaren-Central Michigan website, brochures, newspaper advertisements, billboards, radio scripts, and the quarterly McLaren-Central Michigan publication HealthQuest.

By signing this consent form, the undersigned does hereby release and discharge McLaren-Central Michigan and all persons acting under the permission and authority of McLaren-Central Michigan from liability, damages, compensation or actions arising out of or relating to the testimonial advertisement.

The undersigned demonstrates willing and voluntary participation and full age and capacity for signing such an agreement:

Contact Information

Please fill out the following if you are a relative or guardian giving consent.

The above listed participant is not an emancipated minor or is unable to sign for reasons that will be detailed below.
Therefore, consent is given on the participant's behalf by: