By signing this application, you hereby authorize The Montana Pediatric Cancer Foundation and its duly authorized employees or agents, to disclose your child’s name and personal health information or story that contains your child’s name or likeness and information about your child’s condition or treatment to your child’s healthcare providers in connection with your child’s care and/or for purposes of publications, fundraising, marketing, research programs, publicity, or education, via publication in print, broadcast and electronic media, including social media. Said disclosure may contain information relating to the diagnosis, treatment, and healthcare services provided or to be provided to your child, and other personally identifiable information. You understand that any personal health information or other information so released may be subject to redisclosure by third parties and may no longer be protected by applicable Federal and State privacy laws. You understand that you will not be compensated by The Montana Pediatric Cancer Foundation in any way for the taking or use of your child’s name, personal health information, photographs, films, audio and/or videotapes, or the publishing thereof. You understand that you have the right to revoke this authorization by providing written notice to The Montana Pediatric Cancer Foundation.
This Authorization Form is valid beginning on the date below and valid for one year.