Jackson County Historical Society

Jackson County Counts: Counting Our Stories One at a Time

Standard Release Form

(Complete and submit one form per story, please.)

I donate my story and any accompanying documents, photographs, or artifacts without condition to the Jackson County Historical Society for preservation, and so the material(s) may be made available for scholarly research, exhibit or education into the future.

I understand that while my name may be used to document my story, my personal contact information will not be shared with third parties without my written consent.

Name: ____________________________________ (printed) Date: ______________

____________________________________ (signed)

Address _____________________________________

_____________________________________

Date of birth: _____________________________________

Place of birth: _______________________________________

Date(s) of story: _____________________________________

If you are under 18 years of age, please have a parent or guardian sign, too.

Name: _____________________________________ (printed)

_____________________________________ (signed)

Date: _____________________________________

Return to:

Jackson County Historical Society

112 West Lexington Ave, Ste 103

Independence, MO 64050