Live Better Fan Challenge

If different from above, please provide the contact information for the adult who will be supervising the child at the football game.

I hereby authorize Archboldl Medical Center, together with its employees, agents and contractors, to use images of my child for the marketing purposes as noted below:

Purpose(s) of the Use or Disclosure:

Marketing for Archbold Medical Center and Live Better to try to encourage the use of Archbold Medical Center services and treatment facilities and products by the genreal public and/or community.