Sisters in Survival

First Name *

First Name

Last Name

Agreement *

Peer Mentor Participation & Information Release Agreement I permit the Breast Cancer Network of WNY, Inc. (BCN) to share limited personal and health information I provide to help me participate in BCN’s Peer Mentor Program. This information may include my name, contact details, type of cancer, general treatment information, and relevant background (like age or family situation). This helps BCN match me with the right Peer Mentee. I understand this information will only be shared with my matched mentee, who is expected to respect my privacy. BCN will not share any detailed medical records. My role as a Peer Mentor is to offer emotional support based on my personal experience, not to give medical advice. I also understand that my involvement in this program is voluntary. I can withdraw or cancel my consent at any time by telling BCN in writing. I acknowledge that once I share my information with a mentee, it may no longer be protected by HIPAA. However, BCN requires all participants to keep information strictly confidential. I agree to protect BCN, its directors, officers, employees, and agents (referred to as “BCN”) from any costs (including legal fees), liabilities, damages, claims, or lawsuits that arise from: My failure to keep personal and health information confidential during the program. My failure to follow the rule against providing medical advice in the program. Additionally, I agree to hold BCN harmless for my sharing of personal and health information while in the program. I understand that this agreement to indemnify and hold harmless BCN will remain in effect even after my participation ends and even if I withdraw my consent. This authorization remains in effect as long as I am enrolled in the program or until I provide written notice of cancellation.

I agree