Simply complete this form to submit an enrollment into the Nursing Support Program

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By submitting this request to be enrolled in the Gamifant Cares Nursing Support Program, I authorize that information about me may be released to Sobi Inc. (“Company”) and its third-party suppliers, vendors, and other service providers supporting Gamifant Cares (collectively, the “Service Providers”). I understand that Gamifant Cares and other Service Providers may be compensated by Sobi.

The Service Providers will use and give out my information to assist in my enrollment in Gamifant Cares, if applicable, assess my eligibility for the Nursing Support Program and provide me with educational and other information and materials related to the Nursing Support Program. I understand I will be contacted by a registered nurse to evaluate my eligibility for the Nursing Support Program.

This authorization will last for three (3) years from the date of my agreement. I understand that I do not have to agree to this authorization, but if I do not, I will not have my eligibility for the Nursing Support Program reviewed nor will I be provided with educational, other information and materials related to the Nursing Support Program.

I understand that I have the right to revoke or cancel this authorization, in writing, at any time by providing written notice to the administrators of Gamifant Cares at 50 Bearfoot Road, Northboro, MA 01532. Cancellation of this authorization will be valid when received by the administrators of Gamifant Cares.