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AV Consent Form

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    • Consent authorization

      I voluntarily agree to all Marriage Resource Center of Miami Valley to use my voice, my picture or videotaped recording of me with the following understandings:
    • Name *


    • I give my permission for *





    • Usage scope

    • I give my permission for the following uses *








    • Disclaimer

      I understand that no payment will be exchanged for the permission I give and that any services I am receiving from Marriage Resource Center of Miami Valley will not be affected.
    • Email signature *

    • Last 4 digits of your social security number *

    • Date *


Authentication Text*
(Enter the text in the image above into this field.)

NOTE: Do Not Alter These Fields: