Authorization for Use and Disclosure of Personally-Identifying Information

Authorization for Use and Disclosure of Personally-Identifying Information

for Marketing, Fundraising, Public Relations or Other Purposes
I hereby give my consent for Crisis and Counseling Centers, Inc. ("C&C"), to (select all that apply):*

Photograph meFilm or videotape (includes audio recording) meAudio record meUse my written or oral testimonialOther
I understand and authorize that, depending on their content and context, such photographs, video recordings, audio recordings, testimonials and information could involve disclosure of (select all that apply):*

Mental health information about meSubstance use program information about meFamily Peer Support information about me and my familyMy HIV status (I understand that disclosure of my HIV status could have adverse consequences for me, including discriminatory treatment by others)
I authorize C&C to use, publish, reproduce and disclose the above personally identifying images, recordings testimonials, and information for the following purpose(s) (select all that apply):*

Publication in electronic media (e.g. on C&C's websites, electronic newsletters, promotional, educational/advocacy, or fundraising emails, videos, PSAs)Publication in print media (e.g. newsletters, newspapers, journals, magazines)Broadcasting in television, radio, or streaming media (e.g. television ads, news stories, podcasts, radio commercials)Advertising flyers, posters, displays, exhibits, brochures and similar marketing materialsDirect mailings (e.g. letters, inserts, flyers)Other
By signing this form, you aknowledge your understanding and agreement that:
- C&C will not receive payment for the above uses and disclosures of my information.
- C&C may receive donations or grant funding to advance its mission and provide programming for the above uses and disclosures of my information.
- I have the right to request that the production of the above recordings, films, images, and testimonials cease.
- I have the right to rescind my consent before the above recordings, films, images, and testimonials are used.
- I have the right to revoke this authorization at any time by notifying C&C's Marketing and Public Relations Department at (207) 626-3448, except to the extent that C&C or any other person has already relied upon your authorization.
- C&C will not condition the provision of care upon whether you sign this authorization.
- C&C shall have exclusive ownership rights with respect to the above recordings, films, images and testimonials, unless you resind your consent prior to their production.
- C&C shall have exclusive publication rights with respect to the above recordings, films, images and testimonials, unless you resind your consent prior to their production.
- C&C shall have complete and sole discretion as to whether to use the above recordings, films, images and testimonials for the above purposes.
- The above recordings, films, images and testimonials will NOT be maintained as part of your medical record.
- C&C shall have complete and sole discretion as to how, and the manner in which, the above recordings, films, images and testimonials will be used for the above purposes.
- I am entitled to receive a copy of this authorization.
Signature*

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Name*

First NameLast Name
Date signed*

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Date
If the above named person is a minor or lacks the legal capacity to sign:
Signature of Person's Authorized Representative

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Name of Person's Authorized Representative

First NameLast Name
Authority of Authorized Representative: e.g. parent of minor, guarduian, healthcare power of attorney agent, healthcare surrogate.
Date signed

MonthDayYear
Date
Email *
Upon completing this form you will receive a copy via email for your personal records.
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Authorization for Use and Disclosure of Personally-Identifying Information

By signing this form, you aknowledge your understanding and agreement that: