Missouri wic eat Healthy. Stay Well



Download 6.12 Kb.
Date conversion03.05.2018
Size6.12 Kb.

Missouri

WIC


Eat Healthy. Stay Well.


40 years of WIC – Making a Difference

Video/Audio/Photograph Release Form

Name of Person Submitting Selfie or Group Selfie: ___________________________________

Name of Local Agency: _________________________________________________________

Tell us your story:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I give permission to the MO WIC Association and the DHSS Bureau of WIC and Nutrition Services to use my photo and/or story in advertisement for the 40th year WIC Celebration and for use in print and online outreach materials.

Signature(s):_________________________________________ Date:­­­­­­­­­­­­­___________________



Local Agency Staff, please submit Release Form and Photo to Darla Ketchum at Darla.Ketchum@TMCmed.org.

WIC is an equal opportunity/affirmative action employer.




The database is protected by copyright ©hestories.info 2017
send message

    Main page