Citrin Foundation Ltd.

Consent for use and disclosure of information

I freely give this consent to the Citrin Foundation Ltd. (the “Foundation”), to assist the Foundation and scientific and medical research, as follows:

1. When I provide any information to the Foundation in response to any service, survey or inquiry offered by the Foundation, I agree that the Foundation’s Personal Data Privacy Policy (the “Policy”), https://patient.citrinfoundation.org/privacy-policy/, will apply. If I want to withdraw my consent for storage, management, use and disclosure of my information, I will follow the process stated in the Policy.  I will use the contact information provided in the Policy to make any other requests to the Foundation about my information.
2. I consent for the Foundation to use and disclose any information I provide about me or my minor child’s health or any medical condition, after it is anonymized, for the purposes of scientific and medical research related to citrin deficiency. This may include disclosure to persons who are not employed by or affiliated with the Foundation and the public.
3. I also consent for the Foundation to use any information I provide about me or my minor child’s health or any medical condition, together with identifying or contact information that the Foundation has about me or my minor child, so that the Foundation can contact me about issues, initiatives, projects or programs that the Foundation believes are appropriate for me to know.
4. I understand and agree that the Foundation may use any information I provide, together with identifying or contact information that the Foundation has about me or my minor child, in automated decision-making processes related to: (a) scientific and medical research; and (b) contacting me about issues, initiatives, projects or programs that the Foundation believes are appropriate for me to know.
5. I understand and agree that the information I provide to the Foundation may be received, stored, managed, used and disclosed in countries that have data privacy standards which are different from, or not as protective of my information as, the ones that exist in my country. These countries may include Singapore, the United States of America, Australia, Canada, Japan, the United Kingdom, and any country in the European Union.