Media release

Faculty, staff, resident, fellow student, Volunteer, visitor, patient’s family release for media/public relations/educational purposes

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I authorize The Regents of the University of California (“University”), including UCSD Medical Center, their officers, agents, employees and students, to take photographs of me, to interview me, to publish, print and broadcast my voice and image, and to authorize other persons to do the same. The term “photograph” includes video or still photography, in digital or any other format, and any other means of recording or reproducing images. I understand that my identity may be revealed through my photographs and/or through the use of my name and voice. I agree that the University may use, and authorize others to use, my name, voice and image for public relations and news media purposes, such as for newspapers, web or news television programs, and for educational or research purposes such as to illustrate medical lectures.

My permission is subject to the following limitations:

In All Cases

I waive any right to compensation. I hold The Regents and their designees harmless from and against any claim for injury and or compensation resulting from the activities authorized by this agreement.

The term “photograph,” as used in this agreement shall mean motion picture or still photography in any format, as well as videotape, videodisc, web and any other means of recording and reproducing visual images and sound.

Contact Information

Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone*

Choose One*

Describe if "Other" chosen in previous question*

For Patient’s Family Members: NAME OF PATIENT

Relationship to Patient (if applicable)

Your Email*

Electronic Signature

Type your Full Name*

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Date*

Name

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