Senior Loved One Spotlight Questionnaire
Thank you for being willing to participate in our blog series featuring family members and other loved ones of Minnesota seniors! We are excited to share your story on the Face Aging MN website (www.faceagingmn.org). We will include your first and last name and city of residence unless otherwise indicated by you. You will be contacted and have a chance to review your spotlight blog post before it is posted on the website. Please write in complete sentences.
Full Name *
Your answer
Are you a Minnesota resident? *
Required
Current Minnesota city of residence *
Your answer
Email address *
Your answer
Primary phone number *
Your answer
Questions
Who is a senior in your life who needs care and/or services to age well? What care and/or services is he or she receiving? *
Your answer
What is the most rewarding part of the journey through aging with your senior loved one? *
Your answer
What is the most challenging part of this journey? *
Your answer
Why should senior care issues matter to all Minnesotans? *
Your answer
Future Activity
Would you be willing to share your story in other ways to help Minnesota face aging? Please check the box to indicate interest in each opportunity below: *
Required
Release Form
In order to post your story on www.faceagingmn.org and share a photo and/or video of you, we need you to sign a release form. Please complete the attached release form and return this form and the release form to the person who gave these forms to you. Thank you for helping Minnesota face aging!

RELEASE FORM:
I hereby authorize the Long-Term Care Imperative, the associations it is comprised of and their members, agencies, licensees and assigns to post online and otherwise distribute my original writing submissions as noted on the question form I am submitting along with this release or other original writing submissions that I may submit (“Writing Submissions”).

Writer understands the Writing Submissions are the property of the Long-Term Care Imperative, and unless otherwise stated, that there will be no restrictions on the number of times that the Writing Submission can be used.

Writer understands that his or her name and likeness may be used in connection with his or her Writing Submissions. I authorize the Long-Term Care Imperative to use/take photographs, use/take video, reprint copies of compositions, statements, letters and quotations (hereinafter the "Media Materials"). I further authorize the Long-Term Care Imperative to use and reproduce the Media Materials for marketing, advertising, educational and promotional purposes. I expressly agree that any and all Media Materials created by the Long-Term Care Imperative pursuant to this agreement are the sole property of the Long-Term Care Imperative.

Writer understands that he or she will not be compensated for Writing Submissions or Media Materials sent to the Long-Term Care Imperative or its agents and this agreement does not create an employment relationship of any kind.
Writer understands that submission does not mean Writing Submissions or Media Materials will be published and understands all content may be edited.

Writer understands that he or she may share Writing Submission content in his or her personal social media or blog posts but may not share with or sell to any other organizations for posting or any other distribution.

Writer verifies that Writing Submissions are original work by the Writer and information contained in the Writing Submissions is factual to the best of the Writer’s knowledge.

By making a submission, Writer agrees that the information or materials submitted by the Writer are complete and accurate. The Writer further agrees that it shall indemnify and hold harmless LeadingAge Minnesota and Care Providers of Minnesota, the Long-Term Care Imperative and its agents, licensees and assigns from and against all claims or damages arising out of the use of any information or other materials supplied by the Writer. All errors or omissions are the sole responsibility of the Writer.

Writer understands the terms described in this contract. He/she is over 18-years of age and has the authority to sign this contract and grants the Long-Term Care Imperative and its agents, licensees and assigns the rights given in this agreement.

I agree to the above conditions *
Required
Date: *
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