CCHW Participant Consent/Agreement Form

I agree not to copy, share and/or teach any of the materials provided to me by HealthVisions Midwest. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA, 01923, 978-750-8400, fax 978-646-8600, or on the Web at Materials used with the permission of John Wiley & Sons, Inc. Foundations for Community Health Workers, Tim Berthold, Editor, Second Edition. Copyright © 2016 by John Wiley & Sons, Inc. All rights reserved.

I hereby irrevocably consent to being photographed and authorize the use and reproduction of any and all photographs you have taken of me, negatives, positives, proofs, originals or copies, for whatever purpose, without further compensation to me, and I understand these items are the property of HealthVisions Midwest and may be shared with the Poor Handmaids of Jesus Christ.

I understand that HealthVisions Midwest will record the virtual live sessions and these recordings are the property of HealthVisions Midwest. The purpose of these recordings are to be used for improving our trainings and may be shared with the participants in the class that I am enrolled in as a tool for learning and reviewing in preparation for the exam.

I give my permission to HealthVisions Midwest to add my name to the CCHW and INCHWA email distribution list.

I give my permission to HealthVisions Midwest to share my contact information with INCHWA for membership.

Please type your full name.

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