Photo/video authorization form

Photo/video authorization form

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Contact details

Name*

First Last

Pronouns*

He/Him

She/Her

They/Them

Please select the option that best describes you*

Foundation staff member

Hospital staff member

Sponsor

Corporate/CMN partner

Other

Business name*

Hospital unit/department*

Other*

What event/activity is your photo/video being captured at?*

Home address*

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Daytime phone*

Email*

Email consent

By clicking this box, I give my expressed consent to receive electronic news and information from the Stollery Children’s Hospital Foundation.

I agree photos/videos provided to and/or captured by the Stollery Children’s Hospital Foundation may be used now or in the future for the purpose of: (please check all that apply)*

Website and social media promotion – on the Foundation website(s) and/or social media platforms (including but not limited to: Twitter, Facebook, Instagram, YouTube, stollerykids.com)

Partner/affiliate publication/promotion – can be shared with our affiliates such as the Stollery Children’s Hospital, Alberta Health Services, Women and Children’s Health Research Institute, the University of Alberta, Canada’s Children’s Hospital Foundations

All – can be used for Foundation promotional purposes including, but not limited to website/social media promotion, shared with affiliates and mass media opportunities

Should a large-scale/mass media marketing opportunity arise, every attempt will be made to gain permission and notify you prior to sharing your photo(s)/video(s).

This completed waiver form applies to the following individual(s):*

Please include your name as well as the names of any individuals who are minors that this completed waiver form covers.

Signature*

Date*

MM slash DD slash YYYY

Additional notes

Feel free to include any any additional details surrounding your photo/video sharing permissions.

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