1. This authorization is voluntary.
2. If I do not complete this Authorization, the hospital will not include my loved one's name on the Donor Memorial Wall (Memorial).
3. To have my loved one's name added to the Memorial, he/she must have been a patient at HOSPITAL and meet HOSPITAL's specific criteria.
4. Once completed, HOSPITAL will have one year to place my loved one's name on the Memorial. Once my loved one's name is included on the Memorial, it will remain unless or until any of the following occur: this Authorization is revoked or withdrawn in writing, as described below, or the Memorial is revised to make room for names of additional donors.
5. I may revoke/withdraw this Authorization by mailing or emailing my written request, along with a copy of the original Authorization, to the contact at the bottom of this form. If my loved one's name has already been placed on the Memorial, a withdrawal/revocation would trigger HOSPITAL's removal of my loved one's name. If my loved one's name has not yet been placed on the Memorial, my revocation/withdrawal of this Authorization will prevent HOSPTIAL from placing my loved one's name on the Memorial.
6. Once the identity of my loved one is placed on the Memorial, such information will be available to the public, may no longer be protected by federal and state privacy laws, and could lawfully be re-disclosed by any person who sees it, even if this Authorization is later withdrawn/revoked. Therefore, I understand that neither HOSPITAL nor The LLF will have any liability related in any way to the inclusion of my loved one's name on HOSPITAL's Memorial.
7. I understand that space on the Memorial is limited and that my loved one's name may be removed, without notice to me, to make room for more recent donors.
By selecting submit, you agree that it acts an electronic signature that takes the place of a physical signature and is still considered legally binding.