This section is Optional. The data collected may be shared without any identifying info about the participant with potential current funders)
I do hereby give the above named child permission to take part in the Clubhouse Program.
Dream Builders Group Inc and affiliations understand a respect you and your child’s privacy. There may arise a situation where your child requires medical treatment or medical treatment at a medical facility. To be compliant with the Privacy Law, (HIPAA), enacted by the Federal Government in 2003, Dream Builders Group Inc and affiliations will not disclose any medical information about your child to any individual or individuals that are not in direct care or temporary guardianship of your child without your authorization. Your child’s medical information including any medical documentation that may be completed by a staff member accompanying your child will be kept in a secure place. You have the right to revoke this authorization at any time.
In the event that he/she is injured while participating, I do hereby authorize and consent to any x-ray exam, anesthetic, medical, or surgical diagnosis rendered under the general or special supervision of any licensed medical or dental staff member on the staff of any acute general hospital holding a current license to operate a hospital from the (state of Ohio). It is understood that this authorization is given in advance of any specific diagnosis or treatment being required, but is given to provide authority and power to render care which the aforementioned physician, in his or her best judgment, may deem advisable. It is further understood that efforts shall be made to contact me, the undersigned, prior to rendering treatment to the above named child, but that any of the above mentioned treatments shall not be withheld if I cannot be reached.
I authorize individuals assigned as temporary guardians by Dream Builders Group Inc and affiliations to review my child’s medical release record filed for this event or activity. The review of a medical record will be needed in the event of a medical emergency or to monitor medications or prescriptions being taken by the child.
I authorize individuals assigned as temporary guardians by Dream Builders Group Inc and affiliations to accompany my child to a medical facility in the event of a medical emergency requiring physician intervention.
I authorize individuals assigned as temporary guardians by Dream Builders Group Inc and affiliations to obtain and release medical information to qualified medical personnel when it is deemed pertinent to my child’s illness or injury.
I grant permission for Dream Builders Group Inc to use photographs, still images, and video tapings taken during this event for the sole purpose of decorative enhancements, presentations, publications, and website/internet use to promote Clubhouse. This permission is applicable for current, as well as, future project use.