PERMISSION TO ALLOW THE CHILDREN’S ORGAN TRANSPLANT ASSOCIATION TO ACT ON MY BEHALF
I have read the Patient Agreement and the Children’s Organ Transplant Association (“COTA”) informational materials, and I understand how funds are collected, administered and disbursed.
I certify that the information I provide within this agreement is true and correct to the best of my knowledge. I authorize the Children’s Organ Transplant Association to verify any or all information, including health and life insurance through current employers for wage earners in patient household.
I agree to follow the advice and required guidelines provided by COTA concerning the use of printed materials, fundraising activities, web resources and handling of funds.
I give COTA permission to use the patient’s name, image, voice and medical information (including, without limitation, diagnosis, prognosis, and treatment information) for the purpose of raising funds to support transplant treatments. I further give COTA permission now and in the future to provide such information to any media outlet for the purpose of promoting fundraising and COTA’s broader mission, including increasing public awareness of COTA and its goals not only in support of my situation or campaign, but for other campaigns, or for use by COTA now and in the future. I also agree not to contact the media regarding my circumstances without first contacting COTA.
I agree to exclusively utilize the official campaign website provided by COTA, and will not have another Internet site (including blogs) with patient fundraising information or content. I understand promoting the COTA campaign via social media outlets is encouraged.
I understand that COTA retains the right to alter or delete any information on the campaign website which it deems, in its sole discretion, non-compliant, illegal, inappropriate or incorrect. COTA reserves the right to require edits be made on campaign social media posts that are inaccurate or misleading.
I understand that medical status is an important factor in determining the eligibility for this program and/or success of the program itself. I agree to provide COTA, its employees, agents, and assigns, all medical information, including, without limitation, medical charts and medical bills, and execute all authorizations necessary to obtain such information, as COTA deems necessary to determine my eligibility for the COTA program, to conduct fundraising programs, and to allocate for eligible transplant-related expenses. These expenses are solely determined by COTA and are highlighted in the Patient Agreement.
I understand that funds are the property of COTA and do not belong to the individual patient, community campaign team or patient family.
I understand that this agreement may be terminated at any time for any reason by the patient/family or by the Children’s Organ Transplant Association, upon written notice.