HERO Kids Registry™

Health Emergency Ready Oregon

In an emergency, every moment counts

Only parents, legal guardians, and young adults ages 15-26 may complete this registration form.

At this time, Oregon Resource Parents may not register children in their care.

Please do not add any information to the Registry that you do not want shared with Emergency Providers

Is this a first-time registration?

Are you a young adult age 15-26 registering yourself?

Registration completed by:

Please select one value

Did anyone help you complete this form?

Make a selection by pressing the + button and check all that apply

Authorization to disclose registry information

HERO Kids is an electronic Registry (the “Registry”) developed to help provide critical information on registered children to Emergency Medical Services (“EMS”) and emergency department providers (“Emergency Providers”) in the first few moments of care during an emergency. Your signature below gives the HERO Kids Registry permission to share the information you have provided with Emergency Providers and acknowledges you have read and agreed to the following conditions:

· You understanding that you are solely responsible for the information entered into the Registry and any of the information you provide may be shared with EMS and Emergency Departments. You will not enter any information into the Registry which you do not wish to be disclosed to EMS or Emergency Departments. Further, OHSU and the HERO Kids Registry shall have no liability for disclosure of Registry information to Emergency Providers unless you have revoked my authorization to share such information. · You may revoke your authorization at any time by sending a written statement to herokids@ohsu.edu or by mail to HERO Kids Registry, Mailcode: BTE234, 3181 SW Sam Jackson Park Road, Portland OR 97239 stating you are revoking this authorization. Please include your Registry number in the request. If you revoke your authorization, the information maintained in the Registry may no longer be used or disclosed. However, any uses or disclosures already made with your permission cannot be undone.

I have read this authorization and I understand it. Please sign by [TYPING] your name below.

Unless revoked, this authorization expires THREE YEARS from the date it is signed.

Authorization Signed By:

Authorization Date:

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Signature of parent, legal guardian, or young adult (if completing form for self)

Relationship (Parent, Legal Guardian, or self) to Registrant