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* 1. Please mark all of the NewboRN Home Visiting services you or your infant received:

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* 11. Comments or Suggestions?

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* 12. We would like to have moms share their positive experiences with the
NHVP with others and put those stories on our website. Would you be
interested in writing a paragraph or sharing a photo ? If yes please upload
your story here, read the consent, and fill in your contact information
below.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 13. Please add your contact information if we can contact you for more information about your NewboRN home visit. 

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* 14. By uploading my story, I am agreeing to let NewboRN Home Visiting, legal entity Healthy Start of North Central Florida (hereinafter referred to as Healthy Start) use my likeness in a photograph and/or video, to use my name and photographic likeness in all forms of media for advertising, exposition displays, trade, publicity, illustration, web content, and any other lawful purpose in any and all of its publications, including but not limited to all Healthy Start’s printed and digital publications. I understand and agree that any photograph, photographic likeness, video taken of me and/or recordings made of my voice and/or written extraction, in whole or in part, of such recordings for the purposes of illustration, broadcast, or distribution in any manner will become property of Healthy Start and will not be returned.
I acknowledge that since my participation with Healthy Start is voluntary, I will receive no financial compensation.
I hereby irrevocably authorize Healthy Start to edit, alter, copy, exhibit, publish or distribute this photo and/or video for purposes of publicizing Healthy Start’s programs or for any other lawful purpose. In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my likeness appears.  Additionally, I waive any right to royalties or other compensation arising or related to the use of the photograph.
I hereby hold harmless and release and forever discharge Healthy Start from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
I am at least 18 years of age and am competent to contract in my own name. I have read this release before uploading my story and fully understand the contents, meaning, and impact of this release.

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