The AHCA/NCAL Quality Initiative for Assisted Living Question Title * 1. General Information Your Name Your Position Facility Name Facility Address Email Address Phone Number Question Title * 2. Your Story Question Title * 3. It is okay to contact me about my community's quality story? Yes No Question Title * 4. By submitting my story, I grant to AHCA/NCAL, its affiliates, parents, subsidiaries, and agents the right to copy, store, transmit, modify, distribute, publish, perform, make derivative works from, and otherwise use and/or exploit my story for any purpose reasonably related to the Share Your Story initiative, including but not limited to research, marketing and promotional uses, campaign awareness activities, and internal uses of AHCA/NCAL (e.g., trainings, reports, etc.). I represent to AHCA/NCAL that my story is my original work, and that I did not copy any part of the story from any other party. I further agree that AHCA/NCAL has the right to use my name, likeness, biographical information, and any other material I submit to AHCA/NCAL for any purpose consistent with this grant of permission, without the need to notify me or seek my approval. All grants and permissions given by me to AHCA/NCAL in connection with my submission are given on a royalty-free, worldwide, perpetual, non-cancellable, assignable basis, and will apply in any media now known or later invented. I agree Done