NICU Reunion Children’s is celebrating our patients who “graduated” from our Neonatal Intensive Care Unit (NICU). We are thinking of our tiny fighters and would love to see their progress! If your child was in Children’s NICU and you would like to share a photo of your graduate with our team or Children’s social media, please complete this form. Patient's Name* First Last Patient's Age* Parent/Guardian Name* First Last Email* Phone* Photo upload Max. file size: 32 MB. I authorize my child (or myself) to have medical information about him/her released publicly, for the purposes of publicity and marketing (e.g. photos shared on Children’s social media channels related to NICU reunion, NICU reunion internal communications) by the Marketing & Communications department of Children’s (including Children’s Hospital & Medical Center, Children’s Specialty Physicians, Children’s Physicians & Children’s Foundation), and the content may be shared with Children’s employees and the public. I understand that I may revoke this authorization at any time, except to the extent that action has already been taking in reliance upon it, by giving written notice to Children’s Vice President of Marketing & Communications. I also understand that I may request a copy of this authorization. I understand that refusal to sign this authorization will not affect care received at Children’s, costs or care or eligibility of benefits. My authorization is provided freely, and I understand that I will not receive compensation for the use/disclosure of the information. I understand this authorization is in effect unless Children’s ceases operations. I understand that information used/disclosed pursuant to this authorization may be subject to re-disclosure by third parties and is no longer protected under the HIPAA Privacy Rules. I understand and authorize that the NICU Reunion 2022 information I have submitted here (e.g. photos) will be shared publicly. Yes I authorize the photo I submit to be used for an internal NICU staff presentation ONLY Yes Please check the box below:
