Please complete this enrollment form if you are interested in being matched with a Peer Partner. Once you complete the form, click the submit button at the bottom.


CONTACT INFORMATION:


MEDICAL INFORMATION;

If you are a caregiver, please provide medical information pertaining to the person you cared for.



LIABILITY STATEMENT & CONFIDENTIALITY STATEMENT:

LIABILITY STATEMENT:

Under the Health Insurance Portability and Accountability Act (HIPAA) law, we are required to have your signed consent to participate as a peer volunteer which includes, but is not limited to, your consent to share your personal contact information. By signing this form, you are providing consent for your personal information to be shared in the peer to peer program.


I give you permission to share my personal information which includes, but is not limited to, health information as well as contact information as a part of the Peer Partners program.


I hereby release and forever discharge Emory University, Emory Healthcare, Inc, The Emory Clinic and Emory Winship Cancer Institute and its employees, officers, agents and volunteers from any liability now or in the future arising from my voluntary participation in and/or benefit from this peer support program.


I hereby release and forever discharge Emory University, Emory Healthcare, Inc, The Emory Clinic and Emory Winship Cancer Institute and its employees, officers, agents and volunteers from any claims, demands and causes of action arising from my participation in and/or benefit from this peer support program.


I hereby affirm that I am over the age of eighteen (18) and I have read and fully understand the above and agree to be legally bound by it.


CONFIDENTIALITY STATEMENT:

I agree to keep confidential all such information, whether verbal, written, or computerized, which I learn in the course of my participation in the Peer Partner Program at Winship Cancer Institute of Emory University. I understand and certify that the use of my elctronic signature or digital signature to authenicate documents is the equivalent of my handwritten signature on the documents.