Register:Events:SUNY Upstate Medical University

I understand that this information is being collected to help in providing services under the State Office for the Aging and local Offices for the Aging. It also helps to identify other services that I may need. I understand that this information is needed in order for some services to be provided. The authority to provide these services and to collect my information for these purposes is found in the Older Americans Act and the New York State Elder Law. 
I understand that, per New York State’s Personal Privacy Protection Law, my personal information will be kept confidential. It will not be shared without my permission.   
I understand what information will be recorded, the need for the information, and that there are laws and regulations protecting my information. 
I understand that signing this authorization is voluntary, but that refusal to do so may limit options available to me.

I request and consent to the release by Onondaga County Department of Adult & Long Term Care Services of all requested records, including but not limited to, personal information, health information, and any other information concerning me that I have provided to Onondaga County Department of Adult & Long Term Care Services to the following entities so they can make referrals for services that I may need, or for the purposes identified as follows.
I understand what information will be released, the need for the information and that there are laws and regulations protecting the confidentiality of this information.  I understand that signing this authorization is voluntary, but that refusal to do so may limit options available to me.  I understand that information used or disclosed pursuant to this authorization may be re-disclosed by the recipient and in such an event may no longer be protected by federal or state law.

In the event of a disaster or emergency, I consent to the release of information about services I receive, my housing situation and who I live with, medical equipment or services needed daily, prescription medications taken daily, special dietary needs, special communication needs, blindness or other visual impairments, and information about my general condition and mobility. 
I understand that this information will only be given to those who will use it to respond to an emergency, such as government agencies, law enforcement, or those acting on their behalf if there is a disaster or emergency situation.  
I understand that information used or disclosed pursuant to this authorization may be re-disclosed by the recipient and in such an event may no longer be protected by federal or state law.

I release and discharge State University of New York Upstate Medical University (also known as SUNY Health Science Center at Syracuse), a component of which is University Hospital, State University of New York, and the State of New York, and their respective officers, trustees, directors, employees, and agents for any and all claims, demands, actions, losses, expenses, damages, and liabilities whatsoever in any manner related to or arising out of my participation in programs sponsored by Oasis including, but not limited to, educational, cultural, volunteer, physical fitness related programs, and travel in any form. 

I attest that I have full and informed knowledge of the risks involved in physical fitness activities and have full and informed knowledge of the risks involved in the programs sponsored by Oasis, and I attest that I have obtained approval from my physician(s) to participate in same. 

I understand that the Oasis mailing list may be used by Oasis sponsors for educational mailings. I understand that participants in programs sponsored by Oasis are expected to conduct themselves in a courteous manner, respecting the rights of all other participants, volunteers, and staff. I attest that I will conduct myself in a courteous manner and will respect the rights of all other participants, volunteers, and staff. I understand that if, in the sole discretion of State University of New York Upstate Medical University, I fail to conduct myself in a courteous manner and fail to respect the rights of all other participants, volunteers, and staff, I will not be allowed continued participation in the programs sponsored by Oasis. 

I give permission for The Oasis Institute to photograph or videotape me and to use my name and image in Oasis materials and publicity. I authorize the use of my name and image in publications produced by The Oasis lnstitute’s partners and by the media. I agree to be photographed or videotaped by the media for general publication.

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Register for Online Events

ONLINE Peer Support for Adults with Type Two Diabetes- Online Workshops

10:00:00-12:30:00 Thursday, April 15, 2021