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Authorization for Castilleja School’s Use and Disclosure of Confidential Medical Information

Confidentiality of Medical Information Act (“CMIA”), Civil Code §§ 56.20, 56.21.

Pursuant to California’s Confidentiality of Medical Information Act, I, Castilleja Alumna (named here):

authorizes Castilleja School and its employees, representatives, contractors, and agents, to receive my medical information described in this authorization directly from me and to use such medical information for the limited purposes described in this authorization.

This Authorization Is Limited to the Following Types of Information:
Information regarding my COVID-19 vaccination status.

Castilleja School Is Authorized to Use this Information for the Following Purposes:
For legitimate, non-discriminatory purposes where information regarding my vaccination status is necessary for Castilleja School to:
  1. make school-related decisions authorized by or in order to comply with federal, state, or local laws that take a person’s vaccination status into account; or
  2. to otherwise promote the health and safety of individuals on campus.

The Following Parties Are Authorized to Disclose This Information for the Above Purposes:
Castilleja School and its authorized representatives where:

  1. The disclosure of my vaccination status is or may be impliedly or constructively disclosed by my action(s); and/or
  2. The disclosure of my vaccination status is or may be impliedly or constructively disclosed by action(s) of Castilleja School or its authorized representatives.

The Following Parties Are Authorized to Receive Disclosure of This Information for the Above Purposes: Any agent, representative, or employee of Castilleja School visitor, invitee or other member of the public accessing Castilleja School’s premises or facilities, etc., who may become aware of my vaccination status, by my action(s) and/or those of Castilleja School.

Authorization Period: The parties specified above are authorized to disclose information regarding my COVID-19 vaccination status in the manner specified above through June 30, 2023.

Right to Receive a Copy of This Authorization:
I understand that if I sign this authorization, I have the right to receive a copy of this authorization. Upon request, Castilleja School will provide me with a copy of this authorization.

I authorize the limited uses and disclosures of my medical information as described above for the purposes listed above. I understand that this authorization is voluntary and that I am signing this authorization voluntarily.

Type your name here as your digital signature. ​​​​​

Castilleja Alumna Self-Attestation of COVID-19 Vaccination Status

Castilleja School is requesting information about your vaccination status to promote safe and healthy Castilleja School operations for employees, students, families, and other members of the School community.

Please do NOT provide information related to any health or medical conditions or any other confidential medical information while completing this form. If you provide any such information, Castilleja School will return the form or information to you and require that you complete another attestation without such information.

Campus Alumna Attestation as to Vaccination Status:

You, a Castilleja Alumna named below, attest to the following (select one choice below):

Please select the name of the manufacturer of the COVID-19 vaccine that you received and the date you received the vaccination dose or doses:

Max file size: 10 MB
Type your name here as your digital signature. ​​​