Sports & Recreation participants only
AUTHORIZATION FOR RELEASE OF INFORMATION
Courage Kenny Rehabilitation Institution
3915 Golden Valley Rd
Minneapolis, MN 55422
To provide services to you in the non-healthcare programs of Courage Kenny Rehabilitation Institution (CKRI) may need to use and disclose health-related information about you.
I AUTHORIZE CKRI TO DISCLOSE:
- Name, address, telephone number, e-mail address
A. To be used in the team roster distributed to teammates, coaches and program volunteers.
B. To assist in communication regarding team events, CKRI events and community events.
- Name, address, photos, electronic photos or videos
A. Newspaper, television, radio, CKRI facilities and for use in marketing and fundraising.
B. To increase publicity for the Sports and Recreation programs, individual sports or participant.
I understand that:
- This authorization must be filled out completely to be valid. A copy is as valid as the original.
- CKRI will not refuse to provide services to me based on my refusal to authorize the above mentioned disclosures.
- I may revoke this authorization at any time by notifying CKRI in writing. If I do, it won't affect any actions CKRI took in reliance on this authorization before I revoked it.
- Once information is released to a third party according to this authorization, CKRI cannot prevent its redisclosure.
Consumer's name and signature:
Sign Here
Date 05/07/2024
Signature of consumer or consumer's representative*
*If signed by consumer's representative, please SIGN YOUR name and describe RELATIONSHIP to consumer.
Sign Here
Date 05/07/2024
[Relationship to consumer]
You are entitled to a copy of this authorization form