Whether you've started a new job, completed your education, had a child, got married, or have something else you would like to share, we would love to hear about it!
Do you have a milestone in your recovery? Let us know how long you've stayed sober so we can celebrate together!
If you would like to include a picture with your update, email it to email@example.com.
To include your update in future alumni newsletters, please read the authorization below and click "I agree" on the question "Authorization To Use Proecteded Information"
AUTHORIZATION TO USE/DISCLOSE PROTECTED HEALTH INFORMATION FOR MARKETING,
PUBLIC RELATIONS AND EXTERNAL COMMUNICATIONS
I hereby authorize Mn Adult & Teen Challenge (“MnTC”) to use and/or disclose health information including my recovery story about me for promotional, inspirational, educational and/or informational purposes including (a) on MnTC and its affiliated organization’s websites, print and electronic media, (b) to the public, local, state and national government officials; (c) to reporters for local, state and national media publications, including newspapers, magazines and on-line media; and to reporters for local, state and national television broadcast stations.
I specifically authorize the use and/or disclosure of the following health information: My name, details about my addiction, recovery and my story, my appearance on camera, in still photos or video footage for use in publications (print or electronic), web sites, audio, video, television commercial, advertising or film.
I consent to MnTC’s recording of my voice, name, likeness, image, appearance, performance or story (all referred to as “Images”) by MnTC. I agree that the recording may be created in any form, including, but not limited to, photography, video recording, and digital recording and may be transferred to or duplicated using any form of media now known or later developed, including, but not limited to, digital imaging, computer media file, videotape, film, slides, photographs and audio tapes. I agree that MnTC has the full right to produce, use, copy, distribute, exhibit and transmit Images, including, without limitation, the right to edit, mix or duplicate and to use or re-use Images in whole or part as MnTC may elect. I agree that any Images provided by Me or recorded of Me become the sole and exclusive property of MnTC in perpetuity and that MnTC shall, in its sole discretion, decide if, when, and how Images are to be used. I release MnTC from any and all claims I might otherwise have to control my Images including, but not limited to, claims based on a violation of the right to privacy or right to publicity, defamation, or claims to royalties or compensation of any kind. I agree that this Agreement is binding on Me and anyone who may have rights through Me, including, but not limited to, my legal heirs, personal representatives, trustees, or assigns, and that neither I nor they will have a right to bring any claim or legal action of any kind against MnTC.
I understand that:
1. I may refuse to sign this authorization and that it is strictly voluntary.
2. If I do not sign this form, my treatment and the payment for my treatment will not be affected.
3. I may revoke this authorization at any time in writing, but if I do, it will not have an effect on any actions taken prior to receiving the revocation (i.e. MnTC cannot recall Images once they are in the public domain). Further details may be found in the MnTC Notice of Privacy Practices.
4. Once released the information may be re-disclosed and no longer protected under HIPAA or state or federal law.
5. I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it.
6. I may have a copy of this form after I sign it.
This authorization will expire ten (10) years after the date this form is recieved unless I earlier revoke this authorization as provided above.