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The Chargers Football Company, LLC (the "Club") will collect and process certain personal health information from and about fans and members of the media for the purpose of understanding the health and safety risks posed by SARS-CoV-2, also known as the "coronavirus" and other permitted purposes described below. SARS-CoV-2 is the virus that causes the disease known as COVID-19. Through this consent, the Club is asking each fan and media member that will attend the Club's events, including training camps and games, or will otherwise visit the Club's playing fields or other areas of the Club's facilities[DLA1] , for permission to collect, use and disclose his/her personal health information as described below.

I authorize (i.e., allow) the collection, use and disclosure of my personal health information, described below, which includes any and all medical information protected under applicable state or federal privacy laws (collectively, "Health Information"). In general terms, I understand that Health Information is health or medical information that identifies me or that could reasonably be used to identify me and includes demographic and other identifiable information.

1.  How We Collect Your Health Information. The Club and its affiliates, agents, and service providers (collectively the "LA Chargers," "we," "our," or "us") collect your Health Information from you via an electronic portal or in person.

2.  What Health Information Is Collected, Used and Disclosed. Name, address, personal phone number, email, date of birth, employment details (such as your employer's name and job title), date of COVID-19 vaccination, identification of the vaccine manufacturer, and dates of vaccination dose administration, that will assist the LA Chargers in understanding the risks to players, staff, and members of the public and media posed by COVID-19. 

3.  Who Is Authorized to Receive the Health Information[DLA2] . We will collect your Health Information and may re-disclose it for the purposes described in this consent to the National Football League ("NFL") including the NFL Management Council, authorized vendors and contractors utilized by the NFL and the Club as part of the NFL-NFLPA COVID-19 Protocols, including but not limited to IQVIA, Inc. and Infection Control for Sports ("ICS"), our authorized vendors, including safety consultants and legal counsel, service providers, and others as permitted or required by law.

4.  Purpose(s) for the Collection, Use and/or Disclosure of Health Information:

·   To protect the health and safety of our players, staff, and members of the public and media that will attend Club events or otherwise visit Club playing fields or facilities;

·   To monitor, trace, mitigate, and minimize the spread of COVID-19 within the Club, the communities within which we operate, and/or the NFL;

·   To study best practices and protocols for the detection and prevention of COVID-19;

·   To report information regarding COVID-19 to appropriate public health and safety agencies for lawful public health purposes;

·   To exercise or defend the legal rights of the Club and its employees, affiliates, customers, and service providers; and

·   For other purposes permitted or required by law.

5.  Right to Revoke.

I may revoke (i.e., take back) this consent at any time, except to the extent that the LA Chargers has taken any action in reliance on my consent. I understand that if I revoke this consent, it will not have any effect on any uses or disclosures of my Health Information that occurred prior to the LA Chargers receiving my revocation. To revoke, I understand that I must notify the LA Chargers in writing at the following address or email: [Insert contact information].

6.  Expiration of Consent. 

This consent will remain in full force and effect for one year from the date below, unless I revoke it prior to this time.

7.  Potential for Re-disclosure.

Health Information collected under this consent may be re-disclosed to others. These recipients may not be required by privacy laws to protect the information, and if so, they may share it with others without my permission.