Media Consent and Release

I,   ("I", "me", or "my"), agree as follows:

I authorize Lovelace Health System to take photographs of me and conduct interviews with me in digital, video, and other formats.

I grant to Lovelace Health System and its affiliates and agents (collectively, "LHS") the irrevocable and perpetual right (unlimited as to the number of uses, times and territory) to use, publish and display my testimonials, video, photograph and/or likeness, biographical information and voice (collectively, "Information") in any media now known or later developed for the promotion and/or advertising of LHS and its services, including, without limitation, use in internal and external communications for LHS, social media and Internet distribution.

I agree that LHS owns all rights, including copyright, in all prints, negatives and video taken by LHS and in all works created by or on behalf of LHS incorporating my Information. I understand and agree that I will not receive any compensation of any kind in return for the rights granted by me in this Consent and Release, regardless of whether or not the Information is used at any time by LHS.

I release LHS from all claims now and hereafter existing which I and/or others claiming by or through me may have a right to assert arising under the terms of this Consent and Release or from any use, non-use or editing of the Information.

I understand that I may revoke at any time the rights granted by me in this Consent and Release by notifying LHS in writing; provided, that LHS shall not be required to remove the Information from any works created by or on behalf of LHS prior to receipt of my written revocation.

I understand that typing my name in the box below constitutes a legal signature confirming that I acknowledge and agree to the above terms of this Consent and Release.

First and Last Name of Patient (or Patient's Parent or Legal Guardian)
If Patient is a minor, this form must be signed by Patient's Parent or Legal Guardian.
A copy of the signed form will be emailed to this address.