Click to download the fillable consent form. You may also review the below terms and email SuzanneW@med.unc.edu “yes” to confirm consent.
Digital agreement:
I hereby grant The University of North Carolina at Chapel Hill (“University” or UNC) and Preconception Health and Health Care Initiative (PCHHC) partners the right and permission to use and distribute video and audio footage and/or still photographs (“media”) of me that are taken during my participation in the event and/or activity as described by the PCHHC and UNC team. The intended use of this media is promotion on social and digital media, brochures, publications, Internet website, audiovisual presentations, promotional literature, advertising, or for any other purpose related to the mission of the PCHHC team. I understand that I may not be compensated for the use of the media of me.
I understand and agree that I may be identified by name and title in the information that might accompany the media of me. I agree that all such portraits, pictures, photographs, video, and audio recordings and any reproductions thereof, and all the recording and digital files shall remain the property of The University of North Carolina at Chapel Hill. I hereby release the UNC PCHHC team from any and all claims and demands arising out of or in connection with the use or distribution of said media, including but not limited to, any claims for invasion of privacy, appropriation of likeness, violation of copyright, and/or defamation.
FERPA RELEASE: I understand that the media may be protected by the Family Educational Rights and Privacy Act (“FERPA”) as education records. I hereby authorize the University to release the media from this event to faculty, staff, students, and visitors to of the University, which may include the general public. The purpose of the disclosure is to advance the educational mission of the University.
I hereby warrant that I am eighteen years old or more and competent to contract in my own name. This release is binding upon me and my personal representatives. A copy of this Consent shall have the same force and effect as the original.
PRESENTATION, PHOTOGRAPHY, RECORDING & INFORMATION RELEASE AUTHORIZATION FORM
I authorize UNC Collaborative for Maternal and Infant Health (UNC CMIH) and the PCHHC team members to repost/reshare, take and/or release recordings, and any related information for public relations and/or marketing purposes. By agreeing to the information below, I give permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of PCHHC and UNC CMIH activities. I agree that the PCHHC and UNC CMIH will be allowed to claim partnership for the attributed pictures, etc., and may use them for any purpose consistent with The PCHHC’s mission. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I give permission for any slides, video/audio recordings, screenshots/still images, webinar documents captured during the collaboration/presentation to be disseminated. This includes the use of all information and materials collected in any published form and any media – including rebroadcasting in various formats, platforms, or creative derivates. Full credit to the original source will be given. I acknowledge that I may not receive any compensation, etc., for the use of such pictures, etc., and hereby release the PCHHC, UNC CMIH, and partners from any and all claims which arise out of or are in any way connected with such use.
CONTENT / INFLUENCER COLLABORATION INFORMATION RELEASE AUTHORIZATION FORM
I authorize UNC Collaborative for Maternal and Infant Health (UNC CMIH) and the PCHHC team members to repost/reshare, take and/or release content created by myself, my partners, and/or the CMIH/PCHHC team. I understand my blog posts, photos, and the content will link/redirect to my own online properties, including my website and/or social media channels. By agreeing to the information below, I give permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any content created by myself, my partners, and/or the PCHHC team. I agree that the PCHHC team may use the agreed-upon content for public relations and/or marketing purposes. I agree that PCHHC and UNC CMIH will be allowed to claim my content ‘a contribution from a collaborator’ on the attributed content, and may use them for any purpose consistent with the PCHHC’s mission. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc., for the use of such content, and hereby release the PCHHC, UNC CMIH, and partners from any and all claims which arise out of or are in any way connected with such use.
Click the button below or respond via email/message with a “YES” to agree to these terms.
I understand and agree to the above terms by clicking the below button.
For questions, email SuzanneW@med.unc.edu.