OPENPediatrics Photography and Video Release Form

OPENPediatrics Photography and Video Release Form(Version 1.0)

OPENPediatrics is designed to promote sharing of knowledge about the care of critically ill children, so that doctors and nurses across the globe can have access to colleagues and vital information when they need it. The objective is to provide education on general principles and optimal practice in the diagnosis and care of a critically ill child. I understand Boston Children’s Hospital may have made or would like to make a photograph, film or motion picture of me and/or my child, or a sound recording of me and/or my child’s voice for use within the OPENPediatrics project to assist in demonstrating the latest knowledge in optimal pediatric care.

I authorize Boston Children’s Hospital to make, reproduce, publish, distribute, and otherwise use for all purposes related to OPENPediatrics photographs, videos, and/or sound recordings of me and/or my child. I further consent to and authorize the use of such materials in any electronic distribution, through OPENPediatrics, in whatever manner Boston Children’s Hospital determines in its sole discretion. I expressly waive any approval rights I or my child may have with respect to such materials. I agree that I will not be paid now or in the future for use of my and/or my child’s image or recording. I am aware that Boston Children’s Hospital cannot control how the recipients of OPENPediatrics training use or share the information, and that laws protecting its confidentiality at Boston Children’s Hospital may or may not protect this information once it has been incorporated within OPENPediatrics.

I may cancel this authorization in writing at any time, except in cases where OPENPediatrics has already released an image or video. All revocations must be sent in writing to: OPENPediatrics, Boston Children’s Hospital, Division of Critical Care Medicine, 300 Longwood Avenue, Boston, MA, 02115.

I hereby release and discharge Boston Children’s Hospital, its officers, agents, representatives, successors, and assigns and all persons acting under their permission or authority of and from all liability of any nature arising from my and/or my child’s participation in OPENPediatrics. I expressly release Children’s from any liability for any violation of any personal or property rights relating to the use of my and/or my child’s likeness or personal information that may arise out of the publication, duplication, broadcast or exhibition of our involvement with OPENPediatrics.

I UNDERSTAND THAT THE CARE PROVIDED BY BOSTON CHILDREN’S HOSPITAL WILL NOT BE AFFECTED IF I DO NOT AUTHORIZE THIS RELEASE.

Please identify the title of the video and primary speaker:

Video Title:

Primary Speaker:

Participant's Name
MM slash DD slash YYYY
Please provide contact information