Consent For Use And Disclosure Of Image, Voice And/or Written Testimonials

For good and valuable consideration, receipt of which is hereby acknowledged, I authorize Ogden Regional Medical Center and its respective parents, affiliates, subsidiaries, licensees, successors, and assigns to use the submitted photograph of me/my child including the right to publish my/my child's first name and birth date (collectively, the "Materials"). I understand that for purposes of this consent, the terms "image" and "photograph" encompass still photographs, digital images and any other method to reproduce or edit my/my child's likeness or image now known or hereafter developed.

Ogden Regional Medical Center shall be the owner of the submitted photograph with the right, throughout the world, an unlimited number of times in perpetuity, to copyright, to use, to publish, and to license others to use in any manner, including on the Internet, all or any portion thereof or of a reproduction thereof, free of any payment, royalty, or other compensation of any kind to me. I expressly understand and agree that the Materials and all results and proceeds derived therefrom, shall be the sole and absolute property of Ogden Regional Medical Center for any and all purposes whatsoever in perpetuity, free and clear of all claims whatsoever by me and/or on my behalf. I further represent that any statements made by me during my/my child's appearance or in the Materials are true to the best of my knowledge and that neither they nor my/my child's appearance will violate or infringe upon the rights of any third party. I hereby represent and warrant that I have not given any other person, entity or firm the exclusive right to use my/my child's name, likeness, voice or photograph, and that by signing this document I am not in breach of any other agreement to which I am a party.

I hereby waive any right of inspection or approval of the Materials and my appearance in such Materials and the uses to which such Materials may be put. I agree that the Materials may be edited in the sole discretion of Ogden Regional Medical Center and that Ogden Regional Medical Center is under no obligation to use the Materials. I acknowledge that Ogden Regional Medical Center will rely on this permission potentially at substantial cost to Ogden Regional Medical Center and hereby agree not to assert any claim of any nature whatsoever against anyone relating to the exercise of the permissions granted hereunder.

I hereby acknowledge that I am solely responsible for any statements made by me during the recording of my voice and/or likeness as described above, which statements shall consist solely of my opinions and do not necessarily represent those of Ogden Regional Medical Center, which is not responsible for the content of such statements.

I hereby acknowledge that neither Ogden Regional Medical Center nor any of its agents or employees have made any representations or warranties of any kind with respect to any medical or other advice or information that I may receive in connection with my/my child's appearance and that I have not relied on any such representations or warranties in agreeing to participate in the recording of my voice and/or likeness as described above or in the execution of this Consent for Use and Disclosure of Image, Voice and/or Written Testimonials (the "Consent").

I am signing this Consent as my voluntary act and deed, having read it in its entirety and understanding the contents thereof to my satisfaction, and I acknowledge that it is binding upon me, my legal representatives, heirs and assigns. I understand that this Consent will be signed contemporaneously with the form entitled Authorization for Use and Disclosure of Protected Health Information for Marketing and Promotional Purposes (the "Authorization"), and I agree that in the event of conflict between the two documents, the terms of the Authorization shall govern.