I, __________________________________, authorize ETTA, d/b/a Etta Israel Center (“the agency”), to use and disclose the name, image, likeness, photograph and voice of my child, ____________________, for community education, advertising and fundraising purposes, including written and electronic communications and publications. I understand that the agency is not providing any goods or services in consideration for its use and disclosure of my child’s name, image, likeness, photograph or voice.
In signing this authorization, I understand that: This information may be redisclosed if the recipient is not required by law to protect the privacy of the information, and in that event the HIPAA privacy regulations would not prevent redisclosure and reuse of the information. I have a right to refuse to sign this authorization, and my health care, the payment for health care, and health care benefits will not be affected if I do not sign this authorization. I have a right to see and copy the information described on this authorization form in accordance with agency policies. I also have a right to receive a copy of this form after I have signed it. If I sign this authorization, I will have the right to revoke it at any time, except to the extent that the agency has already taken action based upon this authorization. Unless revoked, the authorization will extend until twelve months after you discontinue receiving services at the agency. To revoke this authorization, please write to ETTA 12722 Riverside Dr. Suite 105 North Hollywood, CA 91607.