IMAGE/RECORDING RELEASE CONSENT FORM
By signing below, I authorize The Richland Hospital and Clinics (“Hospital”) and The Richland Foundation (“Foundation”) (collectively, “Hospital” and “Foundation” will be referred to as “Richland”), to take or record any photographic images, video recordings, audio recordings, (“Images”) for the purpose of internal or external communications, including but not limited to promotional or marketing initiatives. I further authorize Richland to use, disclose, or distribute such Recordings, my name, and other demographic information online, in print, and in news including but not limited to publications, billboards, advertising, television, video, internet and social media, podcasts, radio, or any other manner.
- I authorize Richland to copy, edit, enhance, crop, or otherwise alter the Images.
- I understand and agree that all Images are Hospital’s property and will not be returned to me.
- I affirm that I am giving this consent voluntarily and without obligation, and I acknowledge that that Richland has not conditioned anything on my willingness to sign this consent, including but not limited to treatment, payment, enrollment, and eligibility for benefits.
- I understand that l will receive no compensation for the Images or for my consent to use the Images.
- I understand that if the Images contain protected health information (e.g., if I am a Hospital patient), I must separately complete a compliant authorization allowing such disclosure.
- I understand that this authorization does not expire, and the Hospital may retain the Images indefinitely or may destroy them, at the Hospital’s discretion and without my additional consent.
- I understand that I may withdraw my consent and revoke this authorization at any time although my withdrawal or revocation of this consent will not cause Richland to retract, delete or edit existing marketing material. My withdrawal or revocation of consent will be effective only to the extent that Richland will not use the Images to create new material going forward, after receipt of such withdrawal or revocation. To accomplish such withdrawal or revocation, I understand that I must send a written request to the address listed below or send an email to email@example.com. I understand my revocation is only effective if it is in writing or email.
The Richland Hospital and Clinics
333 East Second Street
Richland Center, WI 53581
- I release and forever discharge Richland and its affiliates, successors and assigns, officers, employees, representatives, partners, agents and anyone claiming through them, in their individual and/or corporate capacities from any and all claims, liabilities, obligations, promises, agreements, disputes, demands, damages, causes of action of any nature or kind, known or unknown, which I, and anyone claiming on behalf of me, may have or claim to have in connection with the Images, including but not limited to claims of violations of copyright, intellectual property, rights of privacy, or rights of publicity, or claims regarding the use or disclosure of Images via third-party website.
- I have carefully read and fully understand the provisions of this authorization, and upon my request, I will be given a copy.