Authorization and Release of Testimonial Information

I understand my testimonial as outlined above (the "Testimonial") and made on behalf of The La Plata Family Centers Coalition (hereinafter called "LPFCC") may be used in connection with publicizing and promoting LPFCC. I authorize LPFCC to use my name, brief biographical information, and the Testimonial as defined on this form.

 Thereby irrevocably authorize LPFCC to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing LPFCC services or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites or in any other distribution media. I agree that I will make no monetary or other claim against LPFCC for the use of the statement.

 In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my testimonial appears.

 I hereby hold harmless and release LPFCC 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.