Coronavirus (COVID-19): Important Information From Tri-City Medical Center Learn more

60th Anniversary Questionnaire & Photo Release Form

Anniversary Photography Consent2021-01-19T09:45:41-08:00

Anniversary Form

60th Anniversary Questionnaire & Photo Release Form
  • PHOTO RELEASE

    The terms photograph and/or video as used in this agreement shall mean any recording identifying an individual or group’s name, image or likeness, including but not limited to video, still photography, sketch or any other electronic or mechanical means of recording and/or reproducing images. The undersigned hereby authorizes Tri-City Healthcare District, it’s employees or agents on behalf of Tri-City Medical Center (individually or together as “Hospital”) to photograph or permit other persons to photograph/video:

    The undersigned agrees that the Hospital, news media personnel or any other marketing agent or publisher may use and permit its employees and associates to use such photographs or videos, including the negatives or reproductions for purposes such as educational, scientific, public relations, advertising/marketing, and charitable purposes. In doing so, the undersigned is also waiving any and all violation(s) of his/her/its Copyright or HIPAA rights. The undersigned has the right to request cessation of recording or filming at any time. The undersigned has the right to rescind consent for use at any time before the recording or film is used or distributed if made in writing to Hospital.

  • Date Format: MM slash DD slash YYYY
X
X