ST. JOSEPH MERCY "THE FARM" VOLUNTEER GENERAL WAIVER & RELEASE FORM.
I hereby hold harmless Trinity Health – Michigan, its affiliates, assignees and licensees including but not limited to St. Joseph Mercy Ann Arbor, and The Farm at St. Joe's (herein after referred to as "Trinity Health"), for bodily injury, personal injury and/or property damage and/or theft to either myself or my child (children) while participating in events at The Farm. I understand participating in events is voluntary and may include physical exertion. I hereby waive any and all rights for any physical, personal, or owned property damages.
Photo Release / Release of Information
HEALTH SYSTEM USE - I hereby give my consent to Saint Joseph Mercy Health System, its affiliates, assignees and licensees to take and use pictures (motion or still, including videotape) of me; as well as use my name, voice and/or verbal statements for medical, educational advertising, proprietary, fundraising or publicity purposes. I understand and agree that such materials, including all negatives, positives, digital images, and prints shall become and remain the sole property of Saint Joseph Mercy Health System and I shall have no right or title to such items and that Saint Joseph Mercy Health System shall have the right to photograph, publish, re-publish, adapt, exhibit, perform, reproduce, edit, modify, make derivative works, distribute, display or otherwise use or reuse my image, voice and/or likeness in connection with any product or service in all markets, media or technology now known or hereafter developed. I agree that Saint Joseph Mercy Health System does not owe me any compensation for the acts that I have consented to in this agreement. I further understand and agree that these materials may be kept on file and used by Saint Joseph Mercy Health System for potential future purposes and further agree to release Saint Joseph Mercy Health System from any and all liability arising from or in connection with the taking, use, publication or dissemination of such materials. I acknowledge receipt of good and valuable consideration in exchange for this release, which may simply be the opportunity to be included in the materials as described above.
OUTSIDE NEWS MEDIA USE - I hereby give my consent to media representatives (newspapers, television, radio and Internet and other third parties approved by Saint Joseph Mercy Health System) to take and use pictures of me and use my statements in their coverage of activities, research or events that involve or take place at Saint Joseph Mercy Health System, its affiliates, assignees and licensees and request that SJMHS permit media representatives to have access to and speak with me for these purposes.
Name (please print) ________________________________________________________________
Name of Parent or Legal Guardian (if under 18 years of age) _______________________________
Signature _____________________________________________ Date ______________________
Intended use Sharing information about and promoting programs at The Farm at St. Joe's
Witnessed by ____________________________________________________________________
YOUR RIGHT TO RESCIND CONSENT
Health System Use - You have a right to rescind consent at any time during taping, filming, recording or photography. To rescind consent, please contact Media Relations at 734-712-4536.
Outside News Media Use – You have the right to request cessation of taping, filming, recording or photography. You also have the right to rescind consent up to the moment the media representatives leave hospital property. Once the media representatives have left the premises, you will not be able to rescind consent. To rescind consent prior to the media’s departure, tell the hospital’s media relations staff member who is accompanying the media while they are in your presence. If they have left your presence, you can page