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I hereby authorize AmberMed to release my child's:

De-identified survey data to the University of Kansas (KU) and the GusNIP Training, Technical Assistance, Evaluation, and Information Center (NTAE).
De-identified demographic information of household to the Kansas Food Bank.
Parent/Guardian -- Name, email, and phone number to be contacted for potential phone interview by the University of Kansas.
Parent/Guardian -- Name, email, address, phone number, and primary language spoken at home to ATTANE Health, for direct home produce box delivery and coaching/education services provided.
Parent/Guardian -- Name and phone number to local Food Pantry staff, Public Health Department, or School for facilitation of additional monthly produce box pick up.
Name to school to see if student participated in nutrition education at school.

Purpose of Release:

Ability to disclose only as needed information for participation in the grant-funded nutrition research program.
Ability to facilitate needed collaborations to allow participant to receive food incentives.

Expiration Date: 1.5 years from signature of this document.

Please Note:

You have the right to revoke this authorization at any time by providing written notification to AmberMed.
This authorization is only valid if signed and dated by the patient or their legal representative.
The above listed medical clinics will only release the minimum amount of information necessary to fulfill the purpose as stated above.

Contact Information: If you have any questions regarding this authorization, please contact AmberMed at (785) 675-3018.

Patient's Name:

Name of Parent/Legal Guardian:

Relationship to Patient:

Today's Date:

By selecting "I consent," you are consenting to the conditions described above.