Authorization and Release of Information for Media/Public Relations, Fundraising, and Marketing

Authorization and Release of Information for Media/Public Relations, Fundraising, and Marketing
I grant One Community Health (OCH) to use my image (photograph and/or video) for use in health clinic marketing, internal and external communications, social media, and informational publications.

I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.

I understand that any information released may be subject to re-disclosure and may no longer be protected by applicable Federal and State privacy laws. I understand that I have a right to revoke this authorization by providing written notice to One Community Health. However, this authorization may not be revoked if One Community Health, its employees, or agents have taken action on this authorization prior to receiving my written notice.

I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to seek treatment or employment with One Community Health.
Please check the paragraph below which is applicable to your present situation:*

I am 18 years of age or older and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, 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 failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.I am the parent or legal guardian of the below named child. I have read this release before signing below, and I fully understand the contents, 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 a free knowledgeable acceptance of the terms of this release.
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