Consent Form
This form is designed to obtain consent from Coalition members, for usage of their organization’s name and logo on the Valley Youth Wellness Coalition Website.
Name of Organization
Type a label
Name of Individual
*
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Statement of Consent:
____________________________________, (“the Organization”) by and through its undersigned authorized representative, hereby gives permission for Valley Youth Wellness Coalition (VYWC) use its organization’s logo on VYWC’s website.
Terms and Conditions
*
I Agree to the Terms and Conditions
I Do Not Agree
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: