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Photo Consent Form_Office Copy.docx - Complete and Return...

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Complete and Return to Volunteer ServicesTopic: ____________________________________Photo/video taken:yesnoRelease #__________________________CONSENT to be in SSM Health News Stories, Educational Materials or PromotionsI consent to be:Photographed or videotapedInterviewedIdentified by nameOther:_____________________________All of the aboveEXCLUSIONSThe undersigned agrees that SSM Health may use and permit other persons to use the consented materials for purposes including, but not limited to,dissemination to hospital staff, physicians, health professionals and members of the public for educational and marketing purposes. Such use issubject only to the following limitations (list, if any):___________________________________________________________________________________________________I understand that:1. My participation is strictly voluntary. If I do not sign this form, my health care and the payment for my health care will not be affected.2. I will receive no compensation for my participation.3. This consent form will expire in 100 years and the materials may be retained indefinitely.

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Term
Spring
Professor
GUY GOEDHARD
Tags
Mass Media, SSM Health

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