Photography/Video
Consent, Waiver, Release and Authorization

(ADULTS AND MINORS)

Consent and Grant of Rights
I, on behalf of myself or if the Subject is a minor on behalf of my minor child, grant to my Physician and AdventHealth a perpetual, irrevocable and unrestricted right to use, reuse, publish and re-publish Subject’s photographic portraits or pictures and/or electronic/digital/video footage of the Subject taken by the Physician or AdventHealth during treatment or those that the Subject posted on social media or the information described below about the Subject’s health care experience and healing at an AdventHealth facility, on the Physician’s personal social media pages and/or AdventHealth social media pages, in which the Subject’s Likeness or Subject’s Story may be included in whole or in part as a composite or distorted in character or form, and whether in conjunction with the Subject’s own name or a fictitious name. The rights granted herein to use the Subject’s Likeness and the Subject’s Story shall extend to any reproductions in color or otherwise, made through any medium and in any and all media now or hereafter known whether used singularly or in conjunction with printed and/or other accompanying material and whether used for any purpose whatsoever, including commercial purposes, and regardless of the manner in which said use is transmitted (e.g., television broadcast, electronic or digital media, printed material, newsprint, brochures, all printed collateral, motion pictures and video).

Waiver of Compensation and Royalties
I waive any right to inspect or approve the finished product or products and/or the advertising copy or other matter containing the Subject’s Likeness or the Subject’s Story. I further waive any right to compensation received by Physician or AdventHealth in association with the commercialization of the Subject’s Likeness or the Subject’s Story, including the sale of said Subject’s Likeness or the Subject’s Story in one or more stock pictures. I waive any and all right to any claim for payment or royalties in connection with the showing of the videotape, photograph, broadcast, or rebroadcast of the Subject’s Likeness or the Subject’s Story and/or regardless of medium (e.g., television broadcast, electronic or digital media, printed material, newsprint, brochures, all printed collateral, motion pictures and video).

Release
I RELEASE AND HOLD HARMLESS ADVENTIST HEALTH SYSTEM SUNBELT HEALTHCARE CORPORATION AND PHYSICIAN FROM ANY LIABILITY BY VIRTUE OF ANY BLURRING, DISTORTION, ALTERATION, OPTICAL ILLUSION, OR USE IN COMPOSITE FORM, WHETHER INTENTIONAL OR OTHERWISE, THAT MAY OCCUR OR BE PRODUCED IN THE CAPTURING AND/OR PROCESSING OF THE SUBJECT’S LIKENESS OR THE SUBJECT’S STORY, AS WELL AS ANY PUBLICATION THEREOF, INCLUDING WITHOUT LIMITATION ANY CLAIMS FOR LIBEL OR INVASION OF PRIVACY.

I warrant that I am over the age of 18 and have the right to contract in my name, or on behalf of the Subject, if the Subject is a minor child. I have read and understand the content of this form prior to signing it. This release shall be binding upon the Subject, his heirs, legal representatives and assigns, and the individual (including the individual’s heirs, legal representatives and assigns) executing this form in those circumstances where the Subject is a minor child.

Authorization
I hereby give Physician and AdventHealth permission to use and share protected health information about the Subject to the general public for the purpose of sharing the Subject’s Likeness or the Subject’s Story in any medium (e.g., television broadcast, electronic or digital media, printed material, newsprint, brochures, all printed collateral, motion pictures and video). The specific protected health information used to tell the Subject’s Story will include and be in reference to the information described below as Subject’s Likeness and Subject’s Story.

I understand this permission may be cancelled at any time by writing to AdventHealth, 900 Hope Way, Altamonte Springs, FL 32714, Attn: Privacy Officer; but if I cancel this permission after Physician or AdventHealth has already created or produced Subject’s Likeness or Subject’s Story on social media, commercials or other publicly available mediums, Physician and AdventHealth will continue using and sharing my protected health information contained in the Subject’s Likeness and the Subject’s Story as permitted by this form before my cancellation. In other words, neither Physician nor AdventHealth will create or produce new stories or projects using the Subject’s Likeness or the Subject’s Story after receipt of your cancellation.

I understand that by permitting this using and sharing of my protected health information, the general public is not required to keep my protected health information that is part of the Subject’s Likeness or the Subject’s Story private as required by the Federal privacy laws.

I understand that signing this form is completely voluntary and I am signing it under my own free will. I understand that Physician and AdventHealth are not making me sign this form in order to get treatment, payment, enrollment in any health plans or to determine my eligibility for benefits.

I understand I will receive a signed copy of this form.