Participant’s Permission to Use Biographical Information

The Dubin Center hosts an annual art exhibit featuring artwork created by those living with dementia. The event is called Brushstrokes from the Soul. Procced from the event support the free services offered through the Dubin Center. 

In order to better illustrate the value of this Event, The Dubin Center would like to share information about individual artists and the therapeutic process involved in the art project. We are requesting your permission to use biographical information in conjunction with art created by you (or your family member).

By signing this document, I _________________________________ (Art project participant) and/or _________________________________________(Guardian – POA – Responsible party) agree to allow The Dubin Center and ___________________________                                              (Facility name)

to use my biographical information as part of the Brushstrokes from the Soul Event and/or to help promote awareness through publicity efforts for The Dubin Center’s Brushstrokes from the Soul Event.

I also give my permission for the art to be used in raising funds and solicitation of donations for the support of The Dubin Center. I give my permission and release for the art image to be used for the benefit of The Dubin Center in any print or online, or commercial medium.

Please initial the following items per your desires (leave blank if ok to use info):

______ Do not use the name of the individual art project participant in the art display or publicity.

 _______Do not use any photos of the individual art project participant.

(Please print clearly the name of the art project participant)

(Participant’s signature – only if able to consent) ___________________________Date___________


(Guardian – POA – Responsible party

Print name and sign next to printed name)                     Date          


(Facility representative – Print name and sign next to printed name)       Date


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