Marketing consent for photography/video

I am filling this form out (check one) *:

Section 1

* Indicates a required field


Guardian information

* Guardians have legal authority to make medical decisions on behalf of the minor.

Child (dependent) information

Personal information

Additional included names (Please include any dependents or family members who should be covered by this release. For example, a child or sibling who is also in the photograph/video).

Section 2

Children’s Minnesota may take, use and disclose photo/video of the individuals listed in Section 1.

Children’s Minnesota (Children’s) may take and use photographs/video of the individuals listed in Section 1 for the purpose of marketing, communications, media and public relations, promotions, events, training, education, fundraising and research.

The photos/video may be shared with: Newspapers; TV news broadcasts; radio; magazines; newsletters; press releases; professional/medical journals; trade or academic publications; video and audio recordings; podcasts; presentations; websites; social media (including the accounts of physicians and other providers of the above health care entities) and other digital media; blogs; documentaries; case or academic studies; professional and staff communications, education, training, research, marketing, fundraising and promotional materials.

I understand that:

  • Refusal to sign this consent will not affect my relationship with Children’s in any way.
  • I will not be compensated (paid) for any use of my child’s/my images/video or story.
  • I can change my mind after I sign this consent and revoke my authorization to use my child’s/my photographs/video. If I revoke my consent, it will not apply to any materials or information already produced or released. The option to stop production or use does not apply to the news media, as they are not under Children’s control.

Signature

Typing your name here means that I have read this information and understand it.