2020 Carriage Club Calendar Project
Child's first name*
Child's last name*
Child's date of birth*
RadDatePicker
RadDatePicker
Open the calendar popup.
Address*
City*
State*
Zip*
Reference Number*
Daytime Phone*
Evening Phone
Email Address*
I have read and understand the letter I received by mail outlining the rules of participation. *
Guardian name
Relationship to child
Please select the photo you would like to submit. MAKE SURE to name the file BabyFirstName-BabyLastName. (for example: Jane-Doe.jpg)*
I am the parent or legal guardian of the above mentioned child and hereby authorize Neosho Memorial Regional Medical Center to disclose protected health information (PHI) concerning my child to the general public through the publication of the 2020 Carriage Club Calendar Project.*

I understand that the PHI to be disclosed includes my child’s first and last name, and city and state of residence, as well as my child’s picture. This disclosure is being made at my request. This authorization shall remain in effect upon submission of the entry and shall remain in effect until 2029. I specifically understand that copies of the 2020 baby calendar may be distributed to the public throughout 2020.  I also understand the calendar information may be distributed using other marketing methods. I understand that I may revoke this authorization at any time (except to the extent that action, such as publication of the calendar, has been taken in reliance on it) by mailing or hand delivering written notification to the following person:

Privacy Officer, NMRMC
P.O. Box 426
Chanute, KS 66720

I understand that treatment at NMRMC is not conditioned on this authorization; however, I understand that my child’s picture cannot be included in the calendar without this signed authorization. I also understand that if the person or entity that receives this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be redisclosed and no longer protected by these regulations.*
Electronic signature of parent or legal guardian*
Date*
Verify Email Address*