Image Consent. Release: I hereby consent and authorize UNMC to take photographs or electronic images of me, and I authorize UNMC to use, reuse, copy, publish, display, exhibit, reproduce, and distribute such information technology in any educational or promotional materials or other forms of media, which may include, but are not limited to University or affiliate hospital publications, catalogs, articles, magazines, recruiting brochures, websites or publications, electronic or otherwise, without notifying me. All employer rights, powers, discretions, authorities and prerogatives are retained by and shall remain exclusively vested in the Board of Regents of the University of Nebraska and the University of Nebraska Medical Center except as clearly and specifically limited by this agreement. Executed this day of 2021. House Officer Board of Regents of the University of Nebraska By: Department Chair Associate Xxxx
Image Consent. In consideration for the right to participate in the Activity, Participant and Parent willingly grant and irrevocably consent to and authorize Releasees the right and permission to photograph, film, video-tape, record, publish, re-publish, broadcast, re-broadcast, adapt, exhibit, perform, reproduce, edit, modify, make derivative works, distribute, display or otherwise use or reuse Participant’s name, image/likeness or voice in media or technology now known or hereafter developed in connection with any product or service in any campaign or promotion in all markets as long as there is no intent to use the image, voice and/or likeness in a disparaging manner. We understand that we will receive no compensation for this agreement. We hereby assign any copyright or other proprietary interest that we might assert in Participant’s participation in the Activity to Releasees. Releasees may exercise any of these rights itself or through any successors, transferees, licensees, distributors or other parties, commercial or non-profit.
Image Consent. I agree to let Bloom on Willow use photos of my bridal party in social media post as examples of bridal day work YES or NO Print Name: Signature: Date: BRIDAL FACT SHEET We recommend you come in a white or like colored to your dress, tank top and a full face of date night makeup. We have on hand earrings, necklaces, decorative hair pieces and a veil for your use if you wish. Trial Option #1...3 hour trial while enjoying a glass of champagne we’ll discuss your wedding style, colors and details to get the feel of what you’re envisioning for your big day. We’ll look over pictures and ideas you have for your hair and choose 3 loose stylies to try. $125
Image Consent. I hereby irrevocably grant to BYU the right to photograph, film, audio record, or otherwise record my image, voice and/or likeness and to use any photograph, image, or likeness of me in connection with the Program (the “Recordings”) for promotional and other purposes without further approval by or compensation to me. I waive my right of privacy in the Recordings. I agree that the Recordings are BYU’s sole and exclusive property, and I consent and grant to BYU and its affiliates and licensees a perpetual license to use my rights of personal identity and publicity, including but not limited to my name, image, and likeness, captured by the Recordings. I release BYU from any and all liability in connection with the use of the Recordings in any media. [ ] (Initial)
Image Consent. 8. The Parties grant permission to the Organization to photograph and/or record the Participants image and/or voice on still or motion picture film and/or audio tape (collectively the “Images”), and to use this material to promote the Organization through the media of newsletters, websites, television, film, radio, print and/or display form and for factual information.
Image Consent. Release: I hereby consent and authorize UNMC to take photographs or electronic images of me, and I authorize UNMC to use, reuse, copy, publish, display, exhibit, reproduce, and distribute such information technology in any educational or promotional materials or other forms of media, which may include, but are not limited to University or affiliate hospital publications, catalogs, articles, magazines, recruiting brochures, websites or publications, electronic or otherwise, without notifying me. All employer rights, powers, discretions, authorities and prerogatives are retained by and shall remain exclusively vested in the Board of Regents of the University of Nebraska and the University of Nebraska Medical Center except as clearly and specifically limited by this agreement. Executed this day of 2019. House Officer Board of Regents of the University of Nebraska By: Department Chair Associate Xxxx Graduate Medical Education CERTIFICATION STATUS: MUST BE COMPLETED BY ALL HOUSE OFFICERS 2009-2010 M.D. Graduates of U.S. Medical Schools or International Medical Graduates: USMLE Step 1 Passed Yes No Month/Year If not, anticipated test date USMLE Step 2 Passed Yes No Month/Year If not, anticipated test date USMLE Step 3 Passed Yes No Month/Year If not, anticipated test date Osteopathic Medical Graduates: COMLEX Part I Passed Yes No Month/Year If not, anticipated test date COMLEX Part II Passed Yes No Month/Year If not, anticipated test date COMLEX, Part III Passed Yes No Month/Year If not, anticipated test date Canadian Medical Graduates: Medical Council of Canada Qualifying Exam, Step I Passed Yes No Month/Year If not, anticipated test date Medical Council of Canada Qualifying Exam, Step II Passed Yes No Month/Year If not, anticipated test date Date: House Officer: VOLUNTARY AUTHORIZATION FOR DEDUCTION OF HOUSE OFFICER ASSOCIATION DUES I, , authorize the University to deduct from salary earned or to be earned by me, membership dues of $2.00/month as certified to the University by the Treasurer of the House Officers Association and to remit the same to the Association. This authorization and direction shall remain in effect from year to year during the period of my employment unless revoked by written notice by me to the University. Social Security Number Address Home Phone
Image Consent. Release: I hereby consent and authorize UNMC to take photographs or electronic images of me, and I authorize UNMC to use, reuse, copy, publish, display, exhibit, reproduce, and distribute such information technology in any educational or promotional materials or other forms of media, which may include, but are not limited to University or affiliate hospital publications, catalogs, articles, magazines, recruiting brochures, websites or publica- tions, electronic or otherwise, without notifying me.
Image Consent. In consideration for the right to participate in the Activity, Participant and Parent willingly grant and irrevocably consent to and authorize Releasees the right and permission to photograph, film, video-tape, record, publish, re-publish, broadcast, re-broadcast, adapt, exhibit, perform, reproduce, edit, modify, make derivative works, distribute, display or otherwise use or reuse Participant’s name, image/likeness or voice in media or technology now known or hereafter developed in connection with any product or service in any campaign or promotion in all markets as long as there is no intent to use the image, voice and/or likeness in a disparaging manner. We understand that we will receive no compensation for this agreement. We hereby assign any copyright or other proprietary interest that we might assert in Participant’s participation in the Activity to Releasees. Releasees may exercise any of these rights itself or through any successors, transferees, licensees, distributors or other parties, commercial or non-profit. If any terms and conditions of this Agreement are held to be invalid or unenforceable as a matter of law, the other terms and conditions hereof shall not be affected thereby and shall remain in full force and effect. Participant and Parent have read and understand this Agreement in its entirety and voluntarily enter into same, without reliance on any representations, statements or inducements, express or implied, made by any party whatsoever. We understand that we have had the opportunity to ask questions or object to any of the terms of this transaction by contacting MTSU. By entering this Agreement, we acknowledge that we fully understand and do not object to any of its terms. Emergency Contact Name Phone Address Participant Signature Date Print Name Gender High School Graduation Year Cell Phone Home Phone Email Date of Birth Address Parent Signature Date Print Name Date of Birth Address Phone
