DNA RESULTS RELEASE FORM

 

     BLAND DNA PARTICIPANT:  Please complete this form after you receive your DNA results.  As a service to other Bland Family members, you are encouraged to share your information publicly.  Nevertheless, the Bland Heritage Foundation (BHF) is sensitive to your privacy.  Completing this on-line form allows you to choose the degree of privacy you wish to maintain.  You may update your privacy options and personal contact data at any time by updating and submitting this form.
     To authenticate your identify, we use an electronic signature using the "Personal Authentication Code" you entered on your original DNA Participation Application.  If you have misplaced your code, you will need to contact the BHF DNA Project Coordinator who will release the code following additional authentication measures to assure your identify.
     Thank you for your participation and attesting to the following agreement:
 

    
DNA RESULTS RELEASE FORM

          "I have reviewed my DNA test results as a Participant in the BHF DNA Project.  I agree to allow the results to be posted with an ID# and the BHF Family Line code, or the oldest known ancestor, as determined by BHF.  In addition, I further agree that the following personal information my be publicized on the BHF website and further waive any claim of liability against BHF, its Board of Directors and Officers, for posting such personal data following submission of this authorization.  Further, I accept the electronic signature system as authentication to this authorization."

Participant's First, Middle, and Last Name*:  

 

Participant's (Kit) ID#*:  

 

Personal Authentication Code*:  

    Enter the same number you chose when submitting your DNA application.

Street Address*:  

 

Address (cont.):  

 

City*:  

 

State/Province/Territory*:

 

Zip/Postal Code*:  

 

Country (only if "NOT SHOWN" is selected in State/Province/Territory):  

 

Home Phone*:  

 

FAX:  

 

E-mail*:  

PERSONAL PRIVACY SELECTIONS

(Uncheck any box you choose not to be published)

"You may publish my . . .
 

                                                                                  . . . Pedigree Chart
                                                                                                      (including the names of any living person is permissible)
                                                                                                      . . . name
                                                                                                      . . . mailing address
                                                                                                      . . . e-mail address
                                                                                                      . . . phone number
                                                                                                      . . . fax number"


You will receive a personal e-mail acknowledgment once we have received your submitted form.
Thank you for participating in the Bland DNA Project.