Today M-D-Y
How many attendees are you registering who currently receive care at Children's? Please fill out their information below.
* must provide value
1
2
3
4
5
Campus in which ______ received treatment.
AMBH
Egleston
Hughes Spalding
Scottish Rite
AMBH
Egleston
Hughes Spalding
Scottish Rite
Campus in which ______ received treatment.
AMBH
Egleston
Hughes Spalding
Scottish Rite
AMBH
Egleston
Hughes Spalding
Scottish Rite
Campus in which ______ received treatment.
AMBH
Egleston
Hughes Spalding
Scottish Rite
AMBH
Egleston
Hughes Spalding
Scottish Rite
Campus in which ______ received treatment.
AMBH
Egleston
Hughes Spalding
Scottish Rite
AMBH
Egleston
Hughes Spalding
Scottish Rite
Campus in which ______ received treatment.
AMBH
Egleston
Hughes Spalding
Scottish Rite
AMBH
Egleston
Hughes Spalding
Scottish Rite
Total Number of Parents / Guardians Attending
* must provide value
1
2
3
4
Parent/Guardian Name
* must provide value
Parent/Guardian's Relationship to attendee
* must provide value
Parent/Guardian Email Address
* must provide value
A confirmation email will be sent to this email so please provide a valid email address.
Parent/Guardian Phone Number
* must provide value
Additional Parent/Guardian Information
Parent/Guardian Name
* must provide value
Parent/Guardian's Relationship to Camper
* must provide value
Parent/Guardian Email Address
* must provide value
A confirmation email will be sent to this email so please provide a valid email address.
Parent/Guardian Phone Number
Additional Parent/Guardian Information
Parent/Guardian Name
* must provide value
Parent/Guardian's Relationship to Camper
* must provide value
Parent/Guardian Email Address
* must provide value
A confirmation email will be sent to this email so please provide a valid email address.
Parent/Guardian Phone Number
Additional Parent/Guardian Information
Parent/Guardian Name
* must provide value
Parent/Guardian's Relationship to Camper
* must provide value
Parent/Guardian Email Address
* must provide value
A confirmation email will be sent to this email so please provide a valid email address.
Parent/Guardian Phone Number
Total Number of Additional Guests Attending
* must provide value
0 1 2 3 4 5 6 7 8
Please give us the name of the first guest.
* must provide value
Please give us the age of the this guest.
* must provide value
Please give us the name of the second guest.
* must provide value
Please give us the age of the this guest.
* must provide value
Please give us the name of the third guest.
* must provide value
Please give us the age of the this guest.
* must provide value
Please give us the name of the fourth guest.
* must provide value
Please give us the age of the this guest.
* must provide value
Please give us the name of the fifth guest.
* must provide value
Please give us the age of the this guest.
* must provide value
Please give us the name of the sixth guest.
* must provide value
Please give us the age of the this guest.
* must provide value
Please give us the name of the seventh guest.
* must provide value
Please give us the age of the this guest.
* must provide value
Please give us the name of the eighth guest.
* must provide value
Please give us the age of the this guest.
* must provide value
Lunch will be generously provided by Chick-fil-A. Please let us know if you or your group have any special food needs or allergies.
CONSENT FORM AND WAIVER (PATIENT & FAMILY)
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH AND OTHER PERSONAL INFORMATION AND/OR PUBLIC USE OF IMAGE (PHOTOGRAPH OR VIDEO) FORMARKETING PROMOTION, MEDIA AND PUBLIC RELATIONS PURPOSES
I hereby give consent to Children's Healthcare of Atlanta Inc. (hereinafter "Children's"), its affiliates, media outlets, community organizations, and/or third parties providing service to Children's to take and use images (photographs or video) or sounds recordings of me and/or the minor patient/person named below for whom I am giving consent (hereinafter the "Patient"), and to disclose such information in any Children's and/or third party media outlet, including radio, television, internet, social media, or print. I understand that the intended use of such images and information may be for advertising, marketing, fundraising or promotional purposes of Children's.
I understand that the information to be disclosed may include protected health information about the Patient's treatment at Children's obtained from interviews of the family, physicians and hospital personnel, or from the patient's medical records. I hereby waive the right to or interest in the confidentiality of this information or images taken and disclosed to the public, as contemplated in this release. I understand that the information disclosed pursuant to this release may be re-disclosed and no is longer protected by any federal or state privacy regulations.
I acknowledge that this consent and authorization for release of confidential information is being made solely for the benefit of Children's and without any expectation of compensation or other benefit to the Patient or the family thereof. While unlikely, Children's may receive direct or indirect remuneration from a third party. To the extent that any benefit accrues or might accrue to Children's from the use of images or disclosure of information, I hereby and forever waive any interest in or claim to such benefits.
I hereby release and forever discharge Children's (including without limitation all corporate affiliates and officers, directors, trustees, employees, medical staff members and agents) from any and all claims, liability, actions, suits, demands, costs, expenses or indebtedness arising out of, related to, or in any way connected with the use of images or disclosure of the information and materials described herein, and I hereby waive all rights and interest in and to such information and materials.
I understand that I may refuse to sign this authorization, that it is strictly voluntary and that my treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this release. I have been informed that this authorization is voluntary and is subject to revocation at any time, except to the extent that action has been taken in reliance thereon, by notifying Children's in writing at: MediaConsents@choa.org.
Expiration:
Authorization is ongoing until Patient reaches age of majority (18yo) unless otherwise revoked.
I agree to the Photographs and Videotape Consent and Release Agreement above.
* must provide value
Yes No
Please sign below to confirm that you agree to the media consent information above.
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Date of Signature
* must provide value
Today M-D-Y
Number of People Attending (Current Record)
View equation
Yes