Protected Health Information: KEYS understands that all protected health information (PHI) about you is personal and we are committed to protecting this information. We create a record of care and services you receive at this agency to provide you with quality care and to comply with certain legal requirements. This notice applies to all records about your care generated by KEYS.
I, hereby agree to release and hold harmless from any liability, KEYS including its paid and volunteer staff executors, administrators, and other agents representing KEYS. This waiver specifically relates to personal injury which may occur while participating in any programs or activity of any kind conducted, approved, organized, or sponsored by KEYS or its representatives. Further, that the consideration for this waiver, is the right, privilege, and opportunity for myself/my child to participate in the programs and activities conducted, approved, organized, or sponsored by KEYS.
If I choose to consent and authorize KEYS to take photographs or motion pictures of myself (and/or my child); or to produce videotapes, audiotapes, closed-circuit television programs, webcasts, or other types of media productions that capture myself (and/or my child’s), voice, and/or image (any of the foregoing types of media are called the “Materials” in this Consent and Release form). I authorize KEYS to copyright the materials, and I authorize KEYS to use, reuse, copy, publish, display, exhibit, reproduce, license to a third party, and distribute the materials in any educational or promotional materials or other forms of media, which may include, but are not limited to university publications, catalogs, articles, magazines, recruiting brochures, websites or publications, electronic or otherwise, without notifying me. I agree with these items to be used up to 99 years after the initial date of use. I agree that I am participating on a voluntary basis and I will not receive any payment from KEYS for signing this release or as a result of any publication of the materials. If I choose to be photographed or recorded, I do not consent or authorize KEYS to take photographs or motion pictures of myself (and/or my child); or to produce videotapes, audiotapes, closed-circuit television programs, webcasts, or other types of media productions that capture myself (and/or my child’s), voice, and/or image (any of the foregoing types of media are called the “Materials” in this Consent and Release form).
I give permission for myself/my youth to participate in KEYS Programming. I give permission for myself/my youth to hold conversations that discuss mental health, police brutality, healthy sex practices, positive peer relationships, and other topics that provide support and promotion for healthy development.
I do understand that there are some services that I will be eligible for and I agree to have MY INSURANCE BILLED by KEYS or an affiliated and authorized 3rd party.
KEYS currently partners with several organizations working to create safer healthier communities. In order to determine where programming should take place and how funding is issued to address social determinants of health, KEYS has to share certain demographic information.
KEYS along with other community organizations fund many programs in Maryland. We want to make sure that these programs help young people. To do this, we check on (evaluate) the programs often. With this form, we ask you to allow us to use your information as we check on your program. If you allow us, we will use some information about you, such as Name, Date of birth, Program participation records, and “Unique school ID” (Student Identification Number), if needed.
KEYS and Family League also work with other agencies in Baltimore City, such as Baltimore City Public Schools. We may use your information to connect to their databases (computer files) and access some or all of the information below: Gender, race, ethnicity, School day attendance, State test scores for math and reading, and iReady test scores.
Plus, we may ask you to fill out a survey. This survey will ask what you think about this program. Your answers will help us check how the program is doing.
No one will use your information in any other way without your permission.
We will keep all your information confidential and private. Only KEYS and Family League staff, researchers, and other approved funding staff will look at your information. Your program staff will not see your information.
When we talk or write about what we find out, we will not share your name. We will not share parts of your information that make it easy for others to know it is you. Instead, we will talk about information about groups of people. Also, we will not use names as we check on how the program is doing.
You may choose to share your information. You may also choose not to share your information.
Either way, you may still take part in your program.
If we give you a survey, you may choose to answer only the questions you want. You may also choose to answer no questions. No money will be paid for letting us use your information or answering our questions. We hope to get information that will make this program better. As programs get better, they will help more people.
If additional information is needed contact email@example.com
An advance directive is a legally binding document that gives instructions for your healthcare in the event that you are no longer able to make or communicate those decisions yourself. For a copy and explanation page. https://www.caringinfo.org/wp-content/uploads/Maryland.pdf