HDC Media Release Form

Project*

By signing this form, you will allow the LSUHSC Human Development Center (HDC) to photograph, videorecord, or audiorecord you or your child for training and outreach purposes related to {project}. Please provide the following information, and the official agreement will appear for you to review. Separate forms are required for each member of your family or household and for each HDC project.

Your Name*

First NameLast Name

E-mail Address*

Your form will be e-mailed to you at this address.

If you are signing for an underage child, type their name below. If you are not signing for a child, then please type N/A in both fields.

Child's Name*

First NameLast Name

The text of the agreement will appear when at least one box from each of the Your Name and Child's Name fields is filled in.

I, {yourName}, hereby grant permission to LSU Health New Orleans to photograph, video tape, record, or interview me (or in the case of a minor, my child {childsName}), for print or broadcast media use, for use in LSU Health New Orleans publications, video or audio tapes, brochures, website, social media, or for use in teaching by LSU Health New Orleans faculty.

I hereby transfer to LSU Health New Orleans all rights and claims I have, or in the future may acquire, with respect to such photographs, video recordings, audio recordings, and/or written materials, agreeing that same shall be the sole and absolute property of LSU Health New Orleans. I hereby relieve and release LSU Health New Orleans from any and all claims whatsoever, and for any and all kinds of remuneration for use of such materials.

Typing your name in the box below has the effect of a signature.

Type name*

Date*

MonthDayYear

Please verify that you are human*

HDC Media Release Form

Agreement