PARTICIPANTS: 4. CKRI Authorization for Release of Information

Registering for Participants 2020-21 - 02/19/2021 12:00 AM - 09/01/2021 12:00 AM Change

Sports & Recreation participants only

AUTHORIZATION FOR RELEASE OF INFORMATION
Courage Kenny Rehabilitation Institution
3915 Golden Valley Rd
Minneapolis, MN 55422

 

Consumer's name: ______________________________________________________________________________ Date ___________________________________
                                                                                   (Please print)

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.

 

_______________________________________________________________________________________          ____________________________________________
Signature of consumer or consumer's representative*                                                                          Date

*If signed by consumer's representative, please PRINT YOUR name and describe relationship to consumer.

 

Printed name: ______________________________________________________________ Relationship to consumer: __________________________________

 

You are entitled to a copy of this authorization form

Who will be participating?

Adult  Adult and Children  Children

Parent / Guardian Information

Sign Here

By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.