Alumni Reunion

I understand that for safety and for legal reasons, all information pertaining to anyone who seeks or has received the services of Ashley, Inc. must be kept confidential. This includes the identity of those who seek services, their names, gender, age, number of children, addresses, types of services received, and place where services were sought or received, and any other information that could identify the individual. I understand that this information is NOT to be shared with anyone including other agencies, treatment providers, law enforcement, or the Department of Social Services, etc. I will maintain the confidentiality of those people I meet through Ashley, Inc. programs, including personal details of the Ashley staff or volunteers. I understand that my confidentiality obligation is on-going and it does not end when my visit to or relationship with Ashley, Inc. ends. I agree to abide by the guidelines above. I understand that failure to respect these confidentiality guidelines may result in me being barred from Ashley, Inc. programs. In addition, depending upon the impact of my confidentiality breach, I may also be subject to civil or criminal liability. This confidentiality agreement was created to ensure the safety and privacy of service recipients, staff and volunteers. I agree to notify an Ashley staff member immediately if I have questions or concerns regarding this confidentiality agreement. The following are not permitted on Ashley, Inc. premises:
• Alcohol
• Backpacks/Tote bags
• Cameras and cell phones
• Non-prescription/illegal drugs
• Electronic Vapor cigarettes
• Food, candy or drinks
• Guns, knives or any item commonly used as a weapon
• Opened packs of cigarettes
• Over the counter medications and vitamins
• Pets
• Purses

AUTHORIZATION FOR USE OF INFORMATION AND IMAGES FOR MARKETING COMMUNICATIONS
Ashley Addiction Treatment is grateful to individuals (e.g., patients, families, and community members) willing to participate in promoting the organization by sharing or participating in photos, stories and experiences related to the organization. Ashley’s staff pledges to maintain strict patient confidentiality in keeping with high ethical standards and in accordance with state and federal law. We require your written permission to use your personal information and/or likeness.

I give permission for Ashley Inc. to create, share or disclose my photographs, video or audio recording, images and basic identifying information, as well as information about my treatment and/or experiences related to the organization in communications. Communications may include, but are not limited to, brochures, advertisements, webpages or social media sites (e.g., Facebook, Twitter, Instagram, YouTube and similar sites) and news media (e.g., TV, radio, newspapers and magazines).
I understand I may withdraw this permission at any time for the FUTURE USE or disclosure of my information, photographs and images by following the guidelines at the top of this form. However, I understand this withdrawal would ONLY affect the FUTURE use and disclosure of my information, photographs and images that have not been previously published. I understand this revocation does NOT apply to the future publication, broadcasting, etc. of my information, photographs or images by media that have previously published, broadcast, etc. the information, photographs or images. Once my information has been disclosed, it may no longer be protected by federal and state privacy laws, and could be re-disclosed by the person or entity who received it. If I authorize any of the uses above, I hereby release and waive all claims to compensation and rights regarding such uses and publication. I am not required to sign this authorization. If I choose not to sign, the organization will not disclose my information as noted above.

ALL PARTICIPANTS AND VOLUNTEERS, BOTH IN PERSON AND VIRTUAL, WILLINGLY PARTICIPATING IN THE ASHLEY REUNION CONDUCTED BY ASHLEY, INC. ARE REQUIRED TO, AND HEREBY DO, ASSUME ALL RISK OF PARTICIPATION IN THE LIVE AND VIRTUAL EVENT BY AGREEING TO THIS GENERAL RELEASE AGREEMENT: The agreed participant, on
behalf of himself/herself/themself and on behalf of their own personal representatives, assigns, heirs, executors, and successors hereby fully and forever releases, waives, discharges and covenants not to sue Ashley Inc. and its affiliated, sponsors, companies and charities, any and all municipal agencies whose property and/or personnel are used or in any way to assist, all sponsoring or co-sponsoring companies or individuals related to the event, together with their officers, directors, shareholders, successors and assigns, (collectively Releases) from all liability to the participant and his/her personal representatives, assigns, heirs, executors and successors for any and all loss(es), damage(s), and any and all claims and demands therefore, on account of injury to participant, his/her property or resultant death, whether caused by the active or passive negligence of all or any Releases or otherwise, in connection with signed individuals participation in the Alumni Reunion.