TOLEDO STATE HOSPITAL
TOLEDO STATE HOSPITAL CEMETERY RECLAMATION PROJECT
RELEASE OF INFORMATION
NAME(please print)________________________________________________DATE______________________
PHONE NUMBER(s)__________________________________________________________________________
PRIVACY INFORMATION
The Toledo State Hospital Cemetery Reclamation Committee (TSHCRC) believes that acknowledging the lives, history and contributions of those buried in the Toledo State Hospital (TSH) cemeteries and those associated with the operation of TSH is an important part of restoring honor and dignity to those buried in the cemeteries. We also believe that increased public awareness of the TSH cemeteries and the history of psychiatric treatment will serve to fight the stigma against mental illness.
Information collected during this oral history project may be used in any or all of the following forums: historical data base, websites, historical publications, and community presentations, displays and events.
All identifying information provided to TSHCRC will be considered confidential unless permission is obtained to make it public. Please review the following privacy options. Your signature acts as authorization to TSHCRC to utilize information in a public forum. Sign only #1 for full authorization.
1. I authorize utilization of all information provided by me.
_____________________________________________________
signature date
[pic]
OR
2. I authorize utilization with the following restrictions:
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________
signature date
THIS SECTION FOR OFFICE USE ONLY
Remarks____________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
Related searches
- hytek medical toledo ohio
- state hospital south fl
- advanced rubber toledo ohio
- toledo public schools staff directory
- wyoming state hospital staff directory
- florida state hospital association
- florida state hospital check stub
- state of florida hospital ratings
- toledo ohio school district map
- toledo public schools state grade card
- alaska state hospital association
- city of toledo water bill