Resident Authorization for Public Disclosure

Form 8 of 12

Note: Fields marked with an * indicates required field

Please indicate 'Yes' or 'No' for each of the following:

I certify that I have received a copy of this authorization and understand that I will not receive financial remuneration for participating in this media project.

This authorization will expire on Dec. 31, 2022. I understand I may cancel this authorization prior to its expiration to prevent the future release of information. Cancellation requests must be submitted in writing to Community Relations, Marwood Nursing & Rehab, 1300 Beard St., Port Huron, MI 48060.

OFFICE USE: Send original to Admissions, provide resident with copy and retain one for the department file.