Charitable Healthcare Network Media and Publicity Use Authorization

Welcome to the Charitable Healthcare Network's Media and Publicity Use Authorization page. Completing this form allows CHN to share impactful stories and promote our mission through photographs, videos, and interviews. Participation is voluntary and does not affect your access to care or services. Thank you for helping us spread the word about the vital work we do together.

Instructions:

1. Click the link below to download the Media and Publicity Use Authorization Form to your device.
2. Open the form and carefully review all the terms and conditions.
3. Complete all required fields, including your name, contact information, and signature.
4. If the participant is under 18, ensure both parents or legal guardians sign the form (unless only one has legal authority).
5. Once completed, return the form to CHN as directed in the document.

Questions? Contact the CHN Office at info@charitablehealth.org or (614) 914-6458.