Releasor consents to and authorizes the release and use of Protected Health Information, which may be protected under federal law, from all medical care facilities, insurance groups and/or social welfare agencies to NNCCF. Releasor further authorizes NNCCF personnel to speak directly with patient’s medical providers and/or social workers. Releasor authorizes NNCCF to release and utilize patient’s medical information as it relates to NNCCF’s non-profit activities.
Releasor consents to the dissemination and use of the patient’s name, likeness, and recorded voice singularly or in conjunction with other photograph’s and/or recording by the print, television, and radio media, for the purposes of pediatric cancer awareness and for raising funds to further the goals of NNCCF (“media consent”). Releasor acknowledges that s/he has the right to revoke this media consent at any time in writing signed by Releasor. The revocation will only be effective upon receipt by a NNCCF.
High school or college transcript
Letter from treating physician
Letter of Recommendation
Essay (include quote that inspires you)
Photo of yourself doing something that inspires you.
Accepted file types: jpg, png, pdf.
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