CONSENT AND RELEASE I (PRINT YOUR NAME) HEREBY

  AUTHORIZATION AND CONSENT FOR DISCLOSURE OF CRIMINAL
APPENDIX H SURROGATE CONSENT PROCESS ADDENDUM THE
BUILDING PLATFORM CHECKLIST (VERSION NOV2019) RESOURCE CONSENT NO

CONSENTIMIENTO INFORMADO PARA LA UTILIZACIÓN DE MUESTRAS BIOLÓGICAS
ELECTROCONVULSIVE THERAPY (ECT) YOUR RIGHTS ABOUT CONSENT
INFORMED CONSENT FORM AND HIPAA AUTHORIZATION STUDY

Release for Photographs and Video For Adult and Minor (00052731.DOC;1)



CONSENT AND RELEASE


I, _________________________________________ (print your name) hereby give the Presbyterian Church (U.S.A.), A Corporation, its affiliated institutions, related entities and its ecumenical partners permission to make and use photographs, images, quotes, video and/or audio recordings of me (or my minor child, identified below) on a perpetual, worldwide, and irrevocable basis in any and all media, including, but not limited to, websites, print, cable, and broadcast media without submission or re-submission to me for approval.


I understand that the photographs, video, images, quotes, recordings, voice and any audio may be used for any and all purposes of the Presbyterian Church (U.S.A.), A Corporation, its affiliated institutions, related entities and its ecumenical partners including use on their web page, cable and broadcast use without re-submission to me for approval. I understand that third parties accessing the web page can download this material, and I release Presbyterian Church (U.S.A.), A Corporation, its affiliated institutions, related entities and its ecumenical partners from any liability to me, my heirs or assigns in connection with or arising out of such downloading by third parties.


By my signature, I hereby certify that I fully understand and agree to this Consent and Release.


IF YOU ARE AN ADULT PLEASE FILL THIS OUT AND SIGN:


Printed Name: __________________________________ Date: ______________


Signature: _____________________________________


By my signature, I hereby certify that I fully understand and agree to this Consent and Release on behalf of the minor listed below and confirm that I am the parent or guardian of that child and I am authorized to give this Release on behalf of the minor.


IF YOU ARE A MINOR (UNDER THE AGE OF 18) PLEASE HAVE YOUR PARENT OR GUARDIAN FILL THIS OUT AND SIGN ON YOUR BEHALF:


Name of Minor: _________________________________ Date: _______________



Printed Name of Parent/Guardian: _____________________________________________



Signature of Parent/Guardian: ________________________________________________


PATIENT ID NUMBER PATIENT NAME INFORMED CONSENT
TERMO DE CONSENTIMENTO DE USO DE BANCO DE
(REV 10919) INFORMED CONSENT FORM (ICF) TEMPLATE INFORMED CONSENT


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