Alone-Together.org Information Authorization Form
I hereby agree to the following:
(1) The information provided may be published and disclosed through the Alone-Together website, promotional materials, art venues, or any additional publications created in association with the Alone-Together organization;
(2) The information provided may vary in content, length, and format, but the essential substance is a written reflection of my personal experiences for the purpose of providing wisdom and hope to other young adults, their families, and the adults who support them.
(3) Any other purposes for disclosure may be allowed at the request of the undersigned individual;
(4) This Authorization will expire when Alone-Together.org is no longer a functioning organization;
(5) Anonymity of any information submitted in connection with this Authorization is not guaranteed;
(6) The undersigned individual retains the right to revoke this authorization at any time via a request made in writing through the "Contact" section on Alone-Together.org;
(7) Any information disclosed in connection with this Authorization is not subject to any protections or privileges found in the Health Insurance and Portability and Accountability Act (HIPPA); and
(8) Alone-Together.org will retain an copy of this form as long as Alone-Together is a functioning organization.
Signature:____________________________________________________ Date: ___________________
Printed Name: _____________________________________________________
Please note- you must be 18 years of age or older.
3. Scan (or take photo)
4. Email as PDF or JPEG to: