Rare Campaign Photograph & Video Release Form printable pdf download

Photograph & Video Release Form

I grant the RARE Campaign Operating Partners—Institute for Clinical Systems Improvement,

Minnesota Hospital Association and Stratis Health—and their employees permission to use my

image, likeness and/or sound of my voice as recorded on audio or video tape or in photographs,

made of on the date listed below, without payment or any other consideration. I understand that my

image may be edited, copied, exhibited, published, or distributed and waive the right to inspect or

approve the finished product wherein my likeness appears. I also waive any right to royalties or

other compensation arising or related to the use of my image or recording. I also understand that this

material may be used in diverse educational settings within an unrestricted geographic area.

Photographic, audio or video recordings may be used for the following purposes:

• conference presentations

• online presentations

• educational presentations or courses

• online and print publications

• informational presentations

• educational videos

By signing this release I understand this permission signifies that photographic or video recordings

of me may be electronically displayed via the Internet or in the public educational setting.

There is no time limit on the validity of this release nor is there any geographic limitation on where

these materials may be distributed.

This release applies to photographic, audio or video recordings collected as part of the RARE

Campaign only.

By signing this form I acknowledge that I am 18 years of age or older and I have read this release

and fully understand the content, meaning, and impact of this release. I understand that I am free to

address any specific questions regarding this release by submitting those questions in writing prior to

signing, and I agree that my failure to do so will be interpreted as free and knowledgeable

acceptance of the terms of this release. I hereby release any and all claims against any person or

organization utilizing this material for educational purposes.

Full Name_____________________________________________________

Organization ___________________________________________________

Street Address/P.O. Box__________________________________________

City ________________________________________________ Zip Code___________________

Phone ___________________________ Fax ___________________________

Email __________________________________________________________

Signature________________________________ Date___________________

(Continue on page 2 for additional participants)

Rare Campaign Photograph & Video Release Form