Hometown Donor Hero Consent Form - Donate Life Indiana

Consent Form

The Hometown Donor Hero program honors donor heroes in your school. This program provides hope to your community by sharing the impact your donor hero’s gift of life made through organ and tissue donation.

Consent Form

Hometown Donor Hero Consent Form

Select the aspects of the Hometown Donor Hero Program that you would like Indiana Donor Network and Donate Life Indiana to complete.

I give Indiana Donor Network and Donate Life Indiana permission to reach out to my loved one's school.

I give Indiana Donor Network and Donate Life Indiana permission to provide graphics to students and staff at my loved one's school to post about my loved one on social media.

I would like Donate Life Indiana to post a tribute for my loved on their social media.

Your name

First

Last

Your email address

Your loved one's name

First

Last

Your loved one's school

Your relationship to your loved one

Media Release

Release for Loved One

I hereby grant the Indiana Donor Network and/or Donate Life Indiana permission to use my loved one's name, photo and/or likeness and/or statements attributed to them that have been previously written or recorded, for the purpose of illustration, advertising, publication, public relations, used as part of a testimonial and/or a memorial or tribute, or for incorporation in video or motion picture film, digital or film still photography, broadcast radio, television, cable or the internet, and used for the purpose of or in conjunction with, the promotion, education and/or create awareness of organ, tissue and eye donation and transplantation.

Your name

First

Last

Your phone number

Address

City

State/Province

Zip/Postal

Signature

Please type full name

If signing for a loved one: I certify that I am the parent, legal guardian or next of kin of the individual named below and I give my consent without reservation to the foregoing on his or her behalf.

Consent Form

Consent Form

Media Release

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