This Authorization Is Limited to the Following Types of Information:Castilleja School Is Authorized to Use this Information for the Following Purposes:
Information regarding my COVID-19 vaccination status.
For legitimate, non-discriminatory purposes where information regarding my vaccination status is necessary for Castilleja School to:
- 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
- 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:
- The disclosure of my vaccination status is or may be impliedly or constructively disclosed by my action(s); and/or
- 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.