[contact-form to=’erin.portillio@jhu.edu, kim.martin@jhu.edu’ subject=’Request to Adapt LARC Materials’][contact-field label=’Name’ type=’name’ required=’1’/][contact-field label=’Position’ type=’text’/][contact-field label=’Project’ type=’text’/][contact-field label=’Organization’ type=’text’/][contact-field label=’Email’ type=’email’ required=’1’/][contact-field label=’Phone’ type=’text’/][contact-field label=’Please specify which materials you wish to use (check all that apply).’ type=’checkbox-multiple’ options=’Brochure with photos,Brochure with illustrations,Poster series (6 posters),Discussion Guide,Video’/][contact-field label=’Please describe how and by whom materials will be used (e.g., posters will be posted in clinics or pharmacies, health workers will use the brochure as job aides, etc.)’ type=’textarea’/]

I/my project/my organization request(s) HC3’s permission to (select one of the following):

[contact-field label=’1. Use the LARC materials as-is, (e.g., otherwise making no changes to materials’ language, images, marking or branding), but will add project/organization logos to the materials before reproducing and disseminating.’ type=’checkbox’/][contact-field label=’If you selected option 1 above, please specify the logos that will be added. ‘ type=’textarea’/][contact-field label=’2. Adapt or alter the materials’ language and images in any way to best suit my country or project context.’ type=’checkbox’/][contact-field label=’If you selected option 2 above, please specify the planned adaptations (e.g., translation, changing phrasing, adding/deleting content, etc.)’ type=’textarea’/][contact-field label=’I acknowledge that selecting option 2 means I will remove both HC3 and USAID logos from the materials before reproducing and disseminating, and will include in their place the following text: These materials were adapted from USAID-funded materials created under the Health Communication Capacity Collaborative (HC3) Project, made possible by the support of the American People. The contents of this adapted material do not reflect the views of USAID or the United States Government. The original materials can be found here.’ type=’checkbox’/][contact-field label=’I will share with HC3 a copy of the revised materials.’ type=’checkbox’/]

I certify everything I have written here is correct to the best of my knowledge:

[contact-field label=’Name’ type=’name’/][contact-field label=’Date’ type=’text’/][/contact-form]

Once a request has been approved, HC3 will share with your organization the InDesign or and/or Word files needed to adapt the materials. Thank you for your interest in using/adapting these materials.