I hereby grant permission for Boston Children's Hospital to disclose to Rotary International, District 6960 the following personal information related to my participation in the course "Building Bridges of Understanding: Behavioral Health Education for Pediatric Primary Care," which is hosted on the Boston Children's Hospital continuing education course site:

first and last name, course completion status, email address, institution, phone number.

I understand that Rotary International may use my personal information to measure participation in the scholarship program they have funded for the course and may, in turn, share this information with the healthcare institution with which I am affiliated. I further understand that Boston Children's Hospital cannot control the use of the data it provides to Rotary International and, therefore, cannot be held liable for any misuse of my data. Finally, I understand that I may withdraw this consent at any time via email to Boston Children's Hospital Continuing Education Department: CMEdepartment@childrens.harvard.edu