How Can We Help? 


Please fill in the form below if The Village Hands can help you. 

How Can We Help? 

Please use your last initial if this is more comfortable
Please tell us about your circumstances

RELEASE STATEMENT:

I hereby grant to The Village Hands (TVH) the permission the unrestricted right and permission
to copyright and use, re-use, publish, and republish pictures and/or likenesses of me and/or my
children, those in which I may be included in whole or in part in any and all media for lawful
purpose including the right to:

Record my participation and or appearance on video tape, audio tape, film, photograph or any
other medium.

Use my name, likeness, voice and biographical material in connection with these recordings.

Exhibit or distribute such recording in whole or in part without restrictions or limitation for any
educational or promotional purposes which TVH and those acting on behalf and authorized to
deem all appropriate.

I hereby agree that I am of full age and have the right to contract in my own name. I have read
the above authorization, release and agreement, and I am fully familiar with the contents
thereof. This release shall be binding upon me and my heirs, legal representatives.

I authorize The Village Hands to release my information to any and all referral agencies to include, but not limited to, child assistance services, hospitals, housing agencies, and any other facilities that may offer assistance with my needs. 

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