Please read and e-sign below. Make sure to have this medical release e-signed and dated by a witness (an adult 18 or older other than yourself). I understand and grant my permission to all my doctors, social workers, clinics and hospitals to release all healthcare and billing information relating to my treatment and care for malignant primary brain tumor and other related health problems to the Darren Daulton Foundation. I also grant my permission to discuss the above information with any designated representative of Darren Daulton Foundation by phone. The Darren Daulton Foundation agrees that all medical information will remain confidential and any reports written about the program will not use any participants’ names without their express permission. I specifically authorize the release of all my healthcare and billing information in your organization’s possession. The purpose of my request is to assist the Darren Daulton Foundation in determining my eligibility for financial assistance. This Release and Authorization shall expire twelve (12) months from its execution if not revoked prior thereto. The Darren Daulton Foundation will not disseminate or release these medical records to any outside source without first obtaining prior express consent. I understand and agree that fulfillment of assistance may result in publicity whether or not the Darren Daulton Foundation actively takes steps to publicize its service. I understand and recognize that the granting of any service and the participation of any person in the assistance is contingent upon approval by the Darren Daulton Foundation. I also understand that there is a limit to the number of services that I will receive, depending on the type and cost of service being requested and offered. I understand and agree that no promises or assurances whatsoever have been made to me by any representatives of the Darren Daulton Foundation regarding the assistance I am requesting.
The Darren Daulton Foundation may hold events and fundraisers throughout the year to raise money to fund the primary objectives of the foundation: to help individuals and/or families endure the staggering cost of malignant brain tumor treatment. People continue to support us because they want to see their money find its way to the people who need it the most. We need your help to put a face and a name to that reality. To this end, we will only use your photo, your name, and your submitted story. If your application is approved, the Darren Daulton Foundation may also use a brief description of how the assistance that you received has helped you. This will facilitate communication with our donors and help in attracting more contributors. Please acknowledge this notice-release by e-signing below:
I hereby acknowledge that if granted financial assistance, the Darren Daulton Foundation may use my name, photo, background and story in PR and marketing materials which will include, but not be limited to, its newsletters, website, mailings and general informational brochures.