Show Us Your Joy!

Little Wishes™ Authorization and Consent to Photograph, Publish, and Release Medical Information

 
I am the parent/legal guardian of child listed on this form ({childsName}) and authorize the use of his/her/my photograph, artwork, and written materials in publications, brochures, other promotional materials, online, and on television and radio broadcasts approved by Little Wishes. The term “photograph,” as used in this agreement shall mean still photography or motion picture in any format, as well as any other mechanical means of recording and reproducing images. I authorize the release of medical information necessary for marketing, public relations, and media purposes approved by Little Wishes. I will not seek compensation for use or reuse of pictures, artwork, or written materials. I waive any right to inspect or approve any pictures, artwork, or written materials prior to their use.
 
Release of liability: This consent is intended to release from liability for use of such photographs, artwork, written materials and medical information Little Wishes, its agents and employees, and anyone publishing them with the permission of Little Wishes.
 
Specific understandings: When your protected health information is disclosed to people or entities that are not required to abide by federal and state medical privacy laws, those people or entities may re- disclose your information to others and use your information without being subject to penalties under those laws.
 
Expiration: This authorization expires at the termination of the specific communications activity in which you have agreed to participate. A communications activity terminates when the health or other information being transmitted through that activity is no longer relevant or useful to Little Wishes communications operations.
 
Right to revoke authorization: You can revoke this authorization at any time before we have relied upon it. Our reliance on your authorization begins as soon as our communications staff has completed the work- product that is the subject of the communications or media relations activity.
 
Please write to us at the following address to revoke this authorization:
Little Wishes, PO Box 2208, San Anselmo, CA 94979.
 
You have the right to refuse to sign this authorization. Your health care, the payment for your health care, and your health care benefits will not be affected if you do not sign this form. You also have the right to receive a copy of this form after you have signed it.