DGS Non-Clinical Bio Submission Form for Website Directory

Your Name
Job Title
Example: (Separate with a coma): English, Spanish, German, French
Primary County You Provide Service for DGS
Example:
Master of Science in Nursing (MSN) – Walden University
Specialty Boards: Psychiatric-Mental Health Nurse Practitioner – American Nurses Credentialing Center
Example:
Please provide 3–4 sentences sharing personal interests, hobbies, passions, or fun facts that help clients and families get to know you outside of your professional role.

Photo / Video Permissions

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.
Please provide a high-resolution, chest-up, color photo with a sharp focus on the eyes and a neutral, uncluttered background.
If you do not have a photo for your bio, and prefer to display the DGS logo instead, select yes below.
Please select one: (copy)
I hereby grant DELAWARE GUIDANCE SERVICES, its directors, officers, employees, agents, and designees non-revocable permission to capture/use I grant Delaware Guidance Services permission to use my name, image, and information submitted in this form in photographs, video, recordings, or other media. I understand that these materials may be used for business purposes, including on websites, social media, publications, advertisements, and other marketing or communications. I acknowledge that Delaware Guidance Services may edit or modify these materials as needed and that I will not receive compensation for their use. I waive the right to review or approve the final use of these materials and release Delaware Guidance Services from any liability related to their use. I confirm that I am at least 18 years old and have the authority to provide this consent.

 

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