1. I, the undersigned, a participant in the publishing of “Share Your Story” with Prairie Cardiovascular, Prairie Heart Institute at HSHS St. John’s Hospital or any other Prairie Heart Institute of Illinois facility (“Prairie”), or the parent, legal guardian, or person otherwise authorized to consent to such participation, hereby consent to the use of any and all still photographs, motion pictures, television and/or video tapes, voice recording, and/or other recordings of my/his/her person at Prairie and agree to the use of my property as follows:
For any educational, training, contribution solicitation, marketing, promotional or other purpose, in any medium whatsoever, by Prairie and/or by any person or persons Prairie may name, and/or for any broadcast or other public viewing. Such publication may be used as described above, in full or edited form, and may be incorporated into other formats and may be copied for multiple distributions and/or broadcast.
2. I agree that I will receive no compensation or other remuneration for the taking, production, use, broadcast, and/or distribution of such publication or for my participation in any manner, and I specifically release Prairie and all others from any liability or other obligation arising from the taking, production, use, broadcast, and/or distribution of such publication.
3. I understand that my consent herein implies that I have obtained permission and consent of any other individual who may appear in any and all still photographs, motion pictures, television and/or video tapes, voice recording and/or other recordings that I have submitted as my own.
4. I understand that I have the right to withdraw from participating in “Share Your Story” at any time, by giving notice in writing to Prairie, and that I have the right to revoke this consent at any time to the extent that Prairie and/or its designee have not relied upon it, or has not submitted the publication for use in external media.
Note: If the participant is under (18) years, the permission of the participant’s parent, legal guardian, or authorized person is required. If the participant decides to revoke his or her authorization please write to Prairie Heart Institute of Illinois, 619 E. Mason St., Room 3P10, Springfield, IL 62701, as soon as that decision is made.