Authorization to use personal information
By signing below, I give permission to Central Vermont Home Health & Hospice and its staff to use and disclose the following items for any lawful purpose, including but not limited to, photo displays, slide shows, videos, audio, brochures, newsletters, annual reports, newspapers, web content, including social media, and/or other informational, marketing and educational materials (in print and electronic formats) at their sole discretion.
- Name
- Photograph/Image
- Age
- Place of Residence
- Occupation and Work History
- Quote/Story
I understand that:
- The above information will be revealed to the public.
- This authorization will expire five years from the date below or sooner if withdrawn or revoked by me.
- I may by written letter withdraw or revoke this authorization at any time.
- The withdrawal or revocation of this authorization will be effective once CVHHH receives it, but it will not be retroactive to the extent that my authorization has been relied on by CVHHH to publish or disclose my Personal Information.
- CVHHH may use my Personal Information without compensation to me.
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