Health Center Testimonial Story
Enter your story, telling the value of ACHC to you. You may also mail or hand deliver your story. (Use "Tab" key to go between field. Don't Use "Enter")
First Name:
Last Name:
E-mail:
Home Address:
City:
State:
Zip:
Enter your full name as permission to allow ACHC to use your story (see below for full release form agreement)
My Story:
Enter your story in the box to the right.
You might find it easier to write your story using a word processor such as Word or Wordpad.Then use the copy and paste capability to place your story into the text box.
Do not use underlining, bold, etc. with your word processor as those attributes will not transfer over to this text box.
Please try to limit your story to no more than 500 words if possible.
Full Release Form:
I hereby give Adams County Health Center consent/permission to use my name, my story and record my image and/or voice to be used in the following ways: Internet/Intranet, Printed newsletters, Media releases, Printed annual report, and requests for funding/appropriations (i.e. grant applications, legislative requests).
I further understand that no special compensation will be provided to me for use of any of my images or information and that I may not be informed in advance of the specific use of such images or information.
