Photography-Video Consent, Waiver, Release and Authorization Form

I, on behalf of myself, or if the Subject is a minor, on behalf of my minor child, grant to AdventHealth on a perpetual, irrevocable and unrestricted basis the right to use, reuse, publish and re-publish Subject’s photographic portraits or pictures and/or electronic/digital/video footage of the Subject that the Subject posted on social media (“Subject’s Likeness”) or the written content, photography or electronic/digital/video footage of Subject’s health care experience and healing at an AdventHealth facility posted on social media (“Subject’s Story”), 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).

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 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).

I RELEASE AND HOLD HARMLESS ADVENTHEALTH 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.

I hereby give 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 referenced below.

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 AdventHealth has already created or produced Subject’s Likeness or Subject’s Story on social media, commercials or other publicly available mediums, AdventHealth will still be able to use and share my protected health information contained in the Subject’s Likeness and the Subject’s Story as permitted by this form prior to my cancellation. In other words, AdventHealth will not create or produce any new stories or projects using the Subject’s Likeness or the Subject’s Story.

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 AdventHealth will not condition treatment, payment, enrollment in any health plans or my eligibility for benefits if I decide not to sign this form.

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

For purposes of this form, the term “AdventHealth” shall include all business entities, which are now or in the future owned or controlled or managed by AdventHealth.