National Alcohol and Drug Addiction Recovery Month
11300 Rockville Pike, Suite 801, Rockville, Maryland 20852
240-221-4361 (phone) – 240-221-4292 (fax)

Authorization and Release

The undersigned, without compensation, hereby authorizes the U.S. Department of Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) to publish personal information and/or photos either donated or produced by the agency in official agency publications, media outlets and advertisements for the public and scientific community, so long as such use is in keeping with established standards of good taste. Provided text may be used in whole or edited into a short, concise version.

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Full Name of Adult of Minor Subject
DHHS/SAMHSA/CSAT may use (check one): My full name and photo:_____;
My first name only and photo:_____;
I prefer that my name not be used and that a pseudonym be used instead with photo____.

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Signature of Adult
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Date

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Signature of Parent of Guardian of Minor Subject
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Date

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Address

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Phone Number

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Witness
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Date

Project Description: National Alcohol and Drug Addiction Recovery Month - Recovery Month highlights the societal benefits of substance abuse treatment, honors substance abuse treatment providers and promotes the message that recovery from substance abuse and addiction is possible. The tool kit and all collateral materials are designed to assist with ideas, suggestions and materials for planning and implementing a successful local campaign. Goals are to educate the target audience concerning substance abuse and the positive outcomes of treatment and recovery. Visit www.recoverymonth.gov for more information.

Note: Be advised that this information will be in the public domain and may be reproduced in its entirety or excerpt pieces in official agency future publications with out further permission.