Name

First

Last

Email

Phone

Select Your County

Which program are you enrolled or interested in?

Bill Payer

Sole-Employer

Co-Employer

What is your role in Self-Determination?

Participant / Employer

Direct Care Professional / Employer / Worker

Family Member

Support Coordinator / Independent Facilitator

OtherOther

What was your transition date to the self-determination program?

Please let us know the name of the person that supported you.

Please tell us about your experience with SequoiaSD.

Would you be willing to share a photo of yourself for SequoiaSD marketing purposes (i.e. testimonial board, feature stories, etc.)? If yes, please read and check the following Photo Release Agreement.

Yes

No

Photo Upload (format - jpg, jpeg, jpe, or png)

Maximum file size: 52.43MB

Photo Release Agreement

By submitting this image or images, I hereby grant SequoiaSD permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.

I understand and agree that all photos will become the property of SequoiaSD and will not be returned.

I hereby irrevocably authorize SequoiaSD to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.

I hereby hold harmless, release, and forever discharge SequoiaSD 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 authorization.

Photo Use Consent

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE AGREEMENT. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE.

Would you be willing to be interviewed by someone from SequoiaSD to learn more about your experience?

Yes

No

Can SequoiaSD use the information provided in this form to share your story for marketing purposes (i.e. testimonial boards, feature stories, etc)? If yes, please read and check the following Testimonial Agreement.

Yes

No

How would you prefer to be contacted?

Phone

Email

Either Phone or Email

What day or days work best for a phone call (choose up to 3)?

What time of day works best for you?

Morning

Afternoon

Evening

Testimonial Agreement

I understand my testimonial as outlined above (the "Testimonial") and made on behalf of SequoiaSD (the "Company") may be used in connection with publicizing and promoting the Company. I authorize The Company to use my name, brief biographical information, and the Testimonial as defined on this form.

I hereby irrevocably authorize the Company to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing the Company’s services or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites or in any other distribution media. I agree that I will make no monetary or other claim against the Company for the use of the statement.

In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my testimonial appears.

I hereby hold harmless and release the Company 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 authorization.

Testimonial Use Consent

I HAVE READ AND UNDERSTAND THE ABOVE TESTIMONIAL AGREEMENT. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE.

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