Consent for Media Follow Up

I give my permission to ACCESS Community Health and Research Center to follow up with me regarding media outreach within and outside the agency in regards to my successes with the Affordable Care Act. I also authorize ACCESS to share my contact information with their media partners to connect with me directly regarding my story.
Name*
First Last
Signature*
Phone*
Applicant Email
Preferred Method of Contact:*
- Phone
- Email
Language(s) Spoken*
- Arabic
- English
- Other (if other, explain in summary)
Date*
MM slash DD slash YYYY
Summary of Story*
Navigator Email*
Navigator ID: MINAVC*