15 Bank Row, Suite D
Greenfield, MA 01302
Tel:413-774-3934
Fax: 774-3946

I ______________________________________ freely give my permission for my image to be posted on the World Wide Web as part of a website for The Charboneau Learning Center of The Literacy Project. I also give my permission for a section of the website to be devoted to representing my efforts as a learner, community member and/or representative of The Literacy Project. I understand that anything about me or any work of mine on the Charboneau Learning Center website will be removed or changed at my request . I also understand that this website is to be used for the sole purpose of promoting the Charboneau Learning Center of the Literacy Project along with its educational and community mission.

Signed __________________________

Date __________________________