QUILT/PHOTO PUBLICATION RELEASE

I hereby give LifeShare Of The Carolinas my permission to use the memorial quilt or pictures of the quilt at special events and in items published by LifeShare or by other organizations for public/professional education on organ and tissue donation. The quilt and/or photographs will be used only as authorized by LifeShare in a sensitive manner.

Donor Name: ____________________________

Family Member: __________________________

Date: __________________________________

Contact Number: _________________________