Thank you for allowing us to be a part of bringing your wonderful miracle into this world.

It is through these caring relationships that we foster lifelong friendships. Let us continue to care for you and your miracle throughout your life. By sharing your birth story with us, we can learn, enhance, and grow together.

Share Your Birth Story

Share Your Birth Story

It’s offering a helping hand... giving a reas­suring smile... going the extra mile...sharing an encouraging word. Simple gestures of kindness often mean the most to us. We hope that during your visit to Prairie Ridge Health you encoun­tered someone who made your experience special. If so, please take a moment to let them know what a dif­ference they made. All those recognized will be presented with an “I CARE” pin.

*CONSENT to be in Prairie Ridge Health News Stories, Educational Materials or Promotions

I consent to be included in the following:

x Public news media (including print, such as newspapers/magazines, and/or broadcast, including TV/radio/Internet)
x Prairie Ridge Health marketing, public relations and educational materials
x To be interviewed
x To be Identified by name

EXCLUSIONS The undersigned agrees that Prairie Ridge Health may use and permit other persons to use the consented materials for purposes including, but not limited to, dissemination to hospital staff, physicians, health professionals and members of the public for educational and marketing purposes.

I understand that:

1. My participation is strictly voluntary. If I do not sign this form, my health care and the payment for my health care will not be affected.
2. I will receive no compensation for my participation.
3. This consent form will expire in 100 years and the materials may be retained indefinitely.
4. I have a right to withdraw my consent at any time by contacting the Prairie Ridge Health Marketing and Community Relations Department at 920-623-2200, until a reasonable time before the materials are used.
5. By signing this form, the personal health care information I relay to an outside source is no longer protected by state and federal privacy laws and may be re-disclosed by that source.
6. I understand that, in the instance of outside sources (such as the news media), Prairie Ridge Health is acting only as the intermediary, making it possible for the aforementioned source(s) to contact me. I agree to hold Prairie Ridge Health and its members, directors, officers and employees harmless from any and all liability arising out of the use and/or release of information, interview, photograph/videotape/film, and subsequent publication or broadcast.

I have read Columbus Community Hospitals release terms and agree to them. I a.m. the person listed above and a.m. sharing my own story. I a.m. the legal guardian of any minors mentioned or photographed in association with this “Share Your Story”. I hold the legal rights to all images I a.m. submitting.