By checking this box, I authorize the Dr. Samuel D. Harris National Museum of Dentistry to share the provided information with the public and to use my name and any images provided, as well as my story in connection with the exhibition project and any educational or marketing material associated with the exhibition, unless otherwise stated within the form.

By checking this box, I understand that my completion of this form does not constitute my inclusion in the Changing Faces exhibition. The museum reviews all entries before including the information in the exhibit, and may reach out to confirm or ask for additional information as necessary. The museum reserves the right to not include an entry into the exhibition, and will notify you of this reason if applicable.