I consent to receive, or if participant is under 18, for my child to receive, emergency medical
treatment in case of injury or illness. The information provided is accurate to the best of my knowledge.

I, the undersigned, hereby consent to participate or allow my child’s participation in a medical learning experience at DRH Health, as sponsored by the EHCO Program. I understand and acknowledge that participation in activities taking place in a health care environment involves inherent risks and hazards, including the risk of exposure to disease and blood/body fluids, and other potential risks. Although I understand that these risks may have serious consequences, on behalf of myself or my child, I hereby expressly assume all of these risks, known or unknown, which could occur through my participation or my child’s participation in the Program, and, on behalf of myself or my child and, I assume personal responsibility for my health or my child’s health and safety while I or my child participates in the Program. In addition, I understand that I am responsible for expenses incurred for any medical or health care services (emergency or otherwise) I or my child may require as a result of participating in the Program. As an inducement for and in consideration of my or my child’s participation in the Program, on behalf of myself or my child, I hereby agree that DRH Health, its subsidiaries and affiliated corporations and their respective directors, officers, employees and agents, will not be liable for any personal injuries, medical claims, damages or other expenses which may occur from my or my child’s participation in the Program. On behalf of myself or my child, I hereby release DRH Health, its subsidiaries and affiliated corporations and their respective directors, officers, employees and agents, from any and all claims or demands which I or my child may now have or have in the future which result from my or my child’s participation in the Program, and, on behalf of myself or my child, I agree not to sue DRH Health, its subsidiaries and affiliated corporations and their respective directors, officers, employees and agents, for any such claims or demands. This Release is intended to be as broad and inclusive as permitted by law, and if any portion of this document is found to be invalid, the rest of this document will remain in effect. This Release shall be binding on my heirs, executors, administrators and assigns. I acknowledge that I have read this document in its entirety or that it has been read to me if I am or have been unable to read it.

By signing below, I agree to all terms and conditions of the following confidentiality agreement. While even though my site tour date may not yet have been determined, I authorize DRH Health to employ this signed agreement and its contents for the duration of my visit to their site. DRH Health and its team members/volunteers must make every effort to prevent unauthorized disclosure of medical, personal, or other data about its patients and team members. We believe it is imperative that as a condition for touring, each student should be familiar with our confidentiality policy. Confidentiality Policy: Any information on a patient concerning their presence in the hospital, their reason for being there, the treatment they are receiving, or their past or current medical condition is confidential and may be released by authorized personnel only. Any knowledge, medical or personal, about a patient is not to be disclosed outside DRH Health. Such information should not be passed from one individual to another inside the hospital. This policy was written to protect the right of the patient from unauthorized disclosure as well as to comply with both State and Federal law. As a routine matter, we must be very conscious as to our conversation outside the workplace. To ensure that you understand the importance of practicing a strict code of confidentiality, we must request that you read and sign the statement below. I fully understand the importance of following the confidentiality code and further understand that disclosure of any information regarding a patient and/or his/her condition may be a violation of Federal and State law and that unauthorized disclosure of confidential information may lead to repercussions.

I do hereby authorize DRH Health, and the DRH Health Foundation to copyright, publish and use (in all forms and media, all manners for advertising trade, promotion, exhibition, or any other lawful purpose whatsoever) still, single, multiple or moving photographic or video portraits of me in which I may be included in whole or in part, or composite or distorted in character or form, in conjunction with my own or fictitious name, or reproductions thereof in color or otherwise for other derivative works made through any medium. I do hereby waive my rights I may have to inspect and/or approve the finished product or advertising copy that may be used in connection therewith, or the use to which is maybe applied. I release DRH Health and the DRH Health Foundation and any other related representative from any liability whatsoever arising, or alleged to arise, by virtue of any form of aural, optical, compositional, or composite distortion that may occur while taking, processing, composing, editing, reproducing, publishing, or displaying said media. I further grant DRH Health, and the DRH Health Foundation with the sole rights to any performance contained in said media.
I am the person named below and have the legal authority to execute the above release. I approve the foregoing and waive any rights in the premises.