Contract of Confidentiality & Release of Information Form


  • I will sign this contract of confidentiality to show that I have the responsibility of maintaining the confidentiality of all children and their families during Children’s Programs. It is expected that during the Children’s Program event, personal information will be discussed. In order to make this comfortable for everyone, it is our policy to ask Children’s Program participants to honor confidentiality as well. It is imperative that whatever is discussed at our Children’s Program not be repeated to anyone. The signature of a parent or guardian indicates that you have explained the above policies to your child(ren) and will assist them in maintaining confidentiality. I understand that Children’s Program facilitators, and/or volunteers cannot keep confidentiality if there is knowledge of intent to harm self or others.

    Give Hospice of Wichita Falls staff permission to photograph, video and/or interview me or my child and to use these images, recordings and/or quotes in training staff and in promoting the Children’s Program to the community via social media, brochures, ads and newspaper articles and other means of publication.

    Give permission to Hospice of Wichita Falls to provide emergency treatment to my child. In the event that appropriate treatment cannot be provided at the program site, I consent for my child to be taken to emergency department where the physician will exercise his/her best judgment as to the diagnosis and treatment. I further consent to any x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital service that may be rendered. I understand that should the need for medical care arise, I will be financially responsible for all costs incurred in rendering or providing medical attention to my child and Hospice of Wichita Falls is not obligated to provide payment for services rendered.

    Give permission for my child (children) to be transported to and from offsite recreation and Hospice of Wichita Falls during Children Program Activities (if applicable). I understand this will include bus services operated by the City of Wichita Falls.