Nemours Photo Consent - Dunkin Prom 2025 for NON patients UNDER 18 years old

Authorization to Release Photo/Video/Audio for Publication

For minors who are NOT Nemours Children's Health patients (18 years or younger)
Name of Minor

First NameMiddle InitialLast Name
D.O.B.
Name* , am the parent or legal guardian of the above-named “Minor” and hereby authorize Nemours Children’s to USE AND/OR DISCLOSE the above-named minor’s information and story with media outlets, social and networks, advertising, websites, public marketing, promotional materials, training and/or presentation and other similar venues.
2. The following people and/or media organizations will have access: Online and printed publications for Nemours Children's Health, Nemours social media accounts, external third-party media outlets, and Dunkin' Joy In Childhood Foundation online and printed media.
3. This authorization will expire

On a specific date (if checked, enter the date)After the completion of the following event/service/project10 years from date this form is signed.
On a specific date (if checked, enter the date)

MonthDayYear
Date
I understand that:
- I can change my mind and revoke this authorization, in writing, at any time, by sending a written revocation to the Nemours Children’s Privacy Officer at 10140 Centurion Parkway North, Jacksonville, Florida 32256 or call 800.472.6610.
- Information used or disclosed may be redistributed by the recipient and may no longer be protected by Federal or state confidentiality law.
  - It is common that disclosures for broadcast or publication will include posting the materials onto Web, social media or similar sites. Once this occurs your information will be publicly available and freely distributed.
- I will receive a copy of this Authorization.
Signature of Legal Guardian

Clear
Date

MonthDayYear
Date
Print Name of Legal Guardian
Description of Personal Representative’s Authority
Personal Representative’s Email
example@example.com
Personal Representative’s Home Phone
Personal Representative’s Cell Phone
Purpose of photo/video:Promote Nemours Prom Events
Situation in photo/video:Nemours Prom 2025
Patient’s gender : Male | Female | Nonbinary | Prefer not to answer
Patient description in photo/video (hair color, clothing):_____
___________________________________________________
Name of staff person:Melissa Nicely
Department:Child Life, Creative Arts Therapy & School Programs
Location:Nemours Children's Health, Delaware
Specific location in hospital or clinic in photo/video: Cafeteria
Date photo/video taken: June 8th, 2025
Nemours Children’s includes: The Nemours Foundation, a Florida not-for-profit corporation, its operating divisions and sites, and its affiliates and subsidiaries, including Nemours Children’s Hospital, Delaware, Nemours Children’s Hospital, Florida, Nemours Children’s Hospital, Surgery Center, Bryn Mawr and Nemours Children’s Hospital, Surgery Center, Deptford; and all entities operating under the name Nemours Children’s Health.

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Authorization to Release Photo/Video/Audio for Publication