Share Your Story - UPMC Children’s Hospital Foundation

Your Name

Child's Name

Your preferred method of contact: (check which apply)

Phone Email

Email:

Phone Number:

Sharing your address with us allows us find and share related events in your area.

Address:

Zip:

Patient Birthdate:

Provide 3-5 sentences about your family’s journey:

Who is your health hero at UPMC Children's?

How would you like to be involved? Check all that apply

Share your family’s story (either in publications, at in-person/virtual events, videos, etc.) Participate in video and photo opportunities Join us for walk Host a fundraiser

UPMC Children’s Hospital Foundation may use/disclose the following information that you provide us. Please check all that apply.

Child’s name and age Photograph(s) Video recording(s) Audio recording(s) Reason for admission Diagnosis, treatment and prognosis All of the Above I would like someone from the Foundation to reach out to me to learn more about my family’s journey or to talk about how I can give back or get involved.

UPMC Children’s Hospital Foundation may use/disclose the health information you provided for marketing, fundraising, and advocacy purposes throughout our and UPMC Children’s Hospital owned channels.

This authorization does not pertain to a specific request, project, event and/or use.

I authorize UPMC to photograph, record and/or interview me, using either a UPMC staff or UPMC approved photographer/videographer and/or reporter. I understand that UPMC, and in some cases the organization with which it has partnered, has/shall have all legal rights to the photography/ recordings/ interviews and that I give up any and all rights to these organizations and will not receive any payment or compensation for the same now or in the future. I understand the photography/ recording/ interview may be used for publicity, education, public information, or paid advertising by UPMC and that the photography/ recordings could appear on UPMC’s website and/or elsewhere on the internet. I hereby release and discharge UPMC, its subsidiaries, and its and their employees, agents, and representatives from any claims, liability or results caused by the use of such photography/recordings and or interview of me as provided herein.

By agreeing to be interviewed about health care services received from UPMC, I authorize UPMC, at its discretion, to interview my UPMC health caregivers (MD, RN and other staff.) I understand that such staff interview may result in a limited disclosure of my protected health information, I the form of facts necessary to ensure the accuracy of any account based on my interview, but that no medical records will be released.

I understand that whether I choose to sign this authorization will in no way influence the health care services provided to me by UPMC. Additionally, I understand that I will not received any special services or compensation in exchange for my agreeing to sign the authorization. I understand that I may revoke this authorization at any time by providing written notice to UPMC addressed to: UPMC Marketing Communications, 600 Grant St, Floor 57, Pittsburgh, PA 15219. However, such revocation shall not affect UPMC’s right to use information, photography/ recordings, and / or interviews made or obtained prior to my revocation of this authorization.

Signature will be good for one year, after one year foundation will reach out to caregiver prior to usage of image and story.

Electronic Signature for consent: (please type in your full name)