Sharing is Caring

2026 Winter STREAK Wellness Program “Sharing is Caring” Submission Photograph and Publicity Authorization

Thank you for your interest in being a part of the Winter STREAK “Sharing is Caring” initiative (the “Initiative”). This is a brand-new component for the 2026 Winter STREAK Wellness Program, designed to celebrate program participation, highlight success stories, and inspire others along their wellness journey.

Each month throughout the program, you can share photos, quotes, and/or stories of how Winter STREAK is helping/has helped you along your wellness journey. To be entered for a chance to win a prize, please be sure to submit your submission(s) prior to the end of each month throughout the program (January-March 2026).

Authorization

I give WellSpan Health and its affiliates (“WellSpan”) permission to use my name, photo, image, and any protected health information (“Information”) that may appear in photos, videos, print or digital materials, and social media I provide as part of this Initiative.

I understand that WellSpan will fully own my Information and can use them for things like promotions, publicity, brochures, advertising, press releases, website content, newsletters, or magazines in any format now or in the future. I know that I will not be paid for the use of my Information for these stated reasons.

I release WellSpan and its employees, officers, and affiliates from any claims or demands related to the use of my Information. This release remains valid even after this authorization is expired or is revoked.

I may revoke this Authorization by notifying the WellSpan Health Privacy Office at privacy@wellspan.org, in writing, of my desire to revoke it. However, I understand that any action already taken in reliance on this Authorization cannot be reversed, and my revocation will not affect those actions.

I understand the following:

  • The Information used or disclosed may be subject to re-disclosure and would no longer be protected by federal privacy provisions.
  • I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or my eligibility for benefits.

My consent expires on March 31, 2028.

My signature acknowledges that I have read and understand the content of this Authorization and all of my questions have been answered.