Fill in all areas then click on Submit button, then check info, then click on print.
Return the form to: Missouri Community Betterment, 1702 Cedar Ridge Way, Branson West, MO 65737.

MCB Permission Statement

I hereby give Missouri Community Betterment permission to use my name, photograph, any information submitted in conjunction with the MCB Awards Competition, information about my circumstances and assistance provided to me by MCB. I understand that this will be used only in educational materials such as MCB brochures, web site materials or news releases to help others understand how MCB programs can help rural communities. This information is not to be used for any commercial, money-making purpose. I will be allowed to review the material relating to me, and approve of its accuracy. This information may be released by MCB for the purpose of conducting outreach activities with the general public. I understand that by signing this consent form, I am waiving any privacy interests I may have in relation to this information under the Privacy Act, 5 U.S.C. 552a, the Freedom of Information Act, 5 U.S.C. 552, and the Trade Secrets Act, 18 U.S.C. 1905.

Sign  ____________________ (sign after printing out)

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