Consent and Release Form for Interviewing, Photographing and Videotaping (United States)

I hereby consent to be interviewed, photographed, filmed, videotaped, have my voice recorded, and/or have my personal likeness recorded through other visual means (collectively, referred to as “Personal Images”), and authorize Health & Science Innovations and and companies with whom it collaborates (collectively, “HSI”) to use, release, publish, exhibit, post on the Internet, in CD-ROMs or any other medium any of my Personal Images, as described below and understand and acknowledge by signing this consent form the following:

• By signing this form, I hereby give permission to HSI to use my Personal Images in whatever medium deemed appropriate by HSI for any of the following purposes: (i) public relations; and (ii) training and education.  HSI will not use the Personal Images for any other purposes. 

• I understand that my Personal Images may be seen and used by HSI throughout the world and hereby give consent to such worldwide use for the purposes stated in this consent form.

• I understand that my consent is voluntary, that I am not required to sign this consent and that I may in fact refuse to sign it, thereby prohibiting HSI from obtaining or using any Personal Images of me.

• I have the right to revoke my consent at any time, which revocation must be in writing and submitted to HSI at the following address:  Health & Science Innovations, Inc., 2060 N. Shadeland Ave, Unite 110, Indianapolis, Indiana 46219.

• I release and discharge HSI, its officers, agents and employees, and each and all persons involved in creating my Personal Images from any liability connected with the taking, recording, filming or publication of said interviews, photographs, slides, computer images, videotapes or voice recordings.

• I waive all rights I may have to claims for payment or royalties in connection with any exhibition, televising, internet posting, or other publication of my Personal Images, irrespective of whether a fee for its use is charged by any third party.  

• If I have any questions about my privacy rights under this form, I understand that I may contact HSI at 317-703-7836 or by writing at the following address:  Health & Science Innovations, Inc., 2060 N. Shadeland Ave, Unite 110, Indianapolis, Indiana 46219.

If the subject of the personal images is 18 years of age or older, the subject should sign below.

I declare that I am eighteen (18) years old or older and am legally competent to execute this Consent and Release Form or that I have acquired the written consent of my parent or legal guardian.  I understand that the terms herein are contractual and not a mere recital, and that this Consent and Release Form is legally binding on me.

I have read and fully informed myself of the contents of this Consent and Release Form before signing it.  I have had an opportunity to ask questions about the use of my Personal Images, understand their purported use, knowingly consent to such use and voluntarily sign this Consent and Release Form.

 You will be provided with a signed copy of this Consent and Release.

If the subject of the personal images is under 18 years old, the parent or legal guardian must sign below.

By signing this Consent and Release Form, I consent to allow the minor named below to participate in the activities described above and allow the information obtained from the below named minor to be used and shared as described above.  I represent and warrant that (i) I am eighteen (18) years of age or older and am legally competent to execute this Consent and Release Form under the laws of my country, (ii) I have the legal authority to represent the below named minor (iii) I have read and understand this Consent and Release Form and (iv) I have had an opportunity to ask questions about the use of the below named minor’s Personal Images, understand their purported use, knowingly consent to such use and voluntarily sign this Consent and Release Form on behalf of the below named minor.

You will be provided with a signed copy of this Consent and Release.

If the subject of the personal images is 13 to 17 years old, they are required to acknowledge that their participation is voluntary by signing below.

You do not have to do this. No one will be mad at you if you refuse to do this or if you decide to quit.

As stated below, I willingly agree to participate in this project.  I understand that my image and personal information may be displayed globally via the means described previously.

You will be provided with a signed copy of this Consent and Release.