CAREGIVER TESTIMONIAL PAGE
 Please enter your information on the Area Office on Aging of Northwestern Ohio,
Inc. Testimonial Release Form. Print, sign and mail Testimonial Release Form to the Area
  Office on Aging. Your telephone number and e-mail address will remain confidential.

   Caregiver Name:

   Caregiver Contact Phone Number:

   Caregiver e-mail address (optional):

   Care recipient Name(s):

   Relationship between Caregiver and Care recipient(s):

   Number of Years Caregiving:

   County of Residence of Caregiver:

   County of Residence of Care recipient:

   State of residence of caregiver if other than Ohio:

   Caregiver Story:
                              Office on Aging of Northwestern Ohio
                                     Testimonial Release Form
I hereby grant the Area Office on Aging of Northwestern Ohio (AOoA) permission to use my
testimonial in any and all of its publications, Web site entries and commercials, without
payment or any other consideration. I understand and agree that these materials will become
the property of the AOoA and will not be returned.

I hereby irrevocably authorize the AOoA to edit, alter, copy, exhibit, publish or distribute this
testimonial for purposes of publicizing the AOoA’s programs or for any other lawful purpose. In
addition, I waive the right to inspect or approve the finished product, including written or
electronic copy, wherein my testimonial appears. Additionally, I waive any right to royalties or
other compensation arising or related to the use of the testimonial.

I hereby hold harmless and release and forever discharge the AOoA 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

I have read this release before signing below and I fully understand the contents, meaning, and
impact of this release.

___________________________________________________________      _______________________
Signature                                                        Date

___________________________________________________________      _______________________
Printed Name                                                     Date

  Thank you for sharing your caregiving story for potential posting on our website! The
 Area Office on Aging of Northwestern Ohio, Inc. reserves the right to edit your story for

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