Enter in the 2025 Calendar Here

Annual Carriage Club Calendar - Entries Welcome

Each year, parents of babies born at Neosho Memorial are invited to enter their child’s photo in the annual Carriage Club calendar project. Invitations to participate were mailed to babies born between April 1, 2023 and April 1, 2024.

If you received an invitation, simply follow the instructions outlined in your letter and complete this online form. Finally, choose and upload your child’s photo.

The deadline is June 16, 2024. If you have questions read our FAQ page or email baby@nmrmc.com.

Waiver: By participating in this project, I hereby, for myself and my child, grant Neosho Memorial and its affiliated institutions and businesses, exclusive rights to use this information for promotional activities. The material I have provided is reproducible and does not violate any copyright laws. With this entry, I, for myself and family, waive all rights and claims for damages I may have against Neosho Memorial Regional Medical Center and any individuals associated with the project.

Nondiscrimination statement: Neosho Memorial Regional Medical Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Interpretation services:
ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-620-431-4000 (TTY: 1-620-431-6586).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-620-431-4000 (TTY: 1-620-431-6586).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-620-431-4000 (TTY: 1-620-431-6586).

Please verify the spelling of your child's name and address! The name will appear in the calendar as submitted on this form.

Child's first name*

Child's last name*

Reference Number *

Child's date of birth*

Open the calendar popup.

Address*

City*

State*

Zip*

Daytime Phone*

Evening Phone

Email Address*

I have read and understand the letter I received by mail outlining the rules of participation. *

True

Guardian name

Relationship to child

Does one or more of the baby’s parents/guardians work for NMRMC?

Yes

MAKE SURE to use the original photo file. Photos copied from facebook, Instagram or other social media site are not accepted.* Take an original photo or use an original file. RENAME THE FILE USING THE BABY'S FIRST--LAST NAME (example: jane-doe.jpg). Hit select to upload. *

I am the parent or legal guardian of the above mentioned child and hereby authorize Neosho Memorial Regional Medical Center to disclose protected health information (PHI) concerning my child to the general public through the publication of the 2022 Carriage Club Calendar Project.*

True

I understand that the PHI to be disclosed includes my child’s first and last name, and city and state of residence, as well as my child’s picture. This disclosure is being made at my request. This authorization shall remain in effect upon submission of the entry and shall remain in effect until 2029. I specifically understand that copies of the 2025 baby calendar may be distributed to the public throughout 2025. I also understand the calendar information may be distributed using other marketing methods. I understand that I may revoke this authorization at any time (except to the extent that action, such as publication of the calendar, has been taken in reliance on it) by mailing or hand delivering written notification to the following person:

Privacy Officer, NMRMC
P.O. Box 426
Chanute, KS 66720

I understand that treatment at NMRMC is not conditioned on this authorization; however, I understand that my child’s picture cannot be included in the calendar without this signed authorization. I also understand that if the person or entity that receives this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be redisclosed and no longer protected by these regulations.*

True

Electronic signature of parent or legal guardian*

Date*

Verify Email Address*

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Annual Carriage Club Calendar - Entries Welcome

The deadline is June 16, 2024. If you have questions read our FAQ page or email baby@nmrmc.com.

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