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Testimonial Permission & Certification Form
CELEBRATING 120 Years Partnering for a Healthy Community Thanks for helping us celebrate by sharing your positive stories about ECMC.
Questions/concerns/oral or emailed presentation of story can be provided to Beth Vallier, bvallier@ewmed.com or 785-472-3111 ext. 328.
	Positive Experience
	I certify that my testimonial is given freely, without compensation or pressure of any kind. By signing this Testimonial Permission and Certification form, I give permission to Ellsworth County Medical Center to use this testimonial in advertisements, marketing material, or promotional literature, with the following exceptions:
	No Exceptions
	Exception
	Exception
	Approximate Month / Year of experience
	Testimonial
	Person providing the testimonial:
	Name
	Date