Triangle, Inc. Media Consent Form

Permission for Release and Use of Photographs/Video Images - 115 CMR 5.04(2)
INSTRUCTIONS:
1. This form must be completed in full, including purpose(s) and expiration.
2. If “Specific Image(s)/Video(s)” is selected, the image(s)/video(s) must be attached. Triangle's team will take care of this.
3. Copies must be distributed as follows:
  - Original: retained by Triangle, Inc. in the individual’s record
  - Copy: provided to the individual and/or guardian/LAR
Please click the name of each section to drop down all the fields.

Click submit at the bottom of the page when you are done.
- Individual's Name*
  
  First NameLast Name
- Date of Birth*
  
  MonthDayYear
  Date
- Triangle Location*
- I give permission for Triangle, Inc. to take and use photographs and/or video images of me captured during activities, events, and/or in Triangle, Inc. program settings for the purposes I select in Section III. Starting from the date this authorization is signed, Triangle, Inc. does not have to get my permission for additional uses or future release of the specific image(s) and/or information that I authorized in this release.
- I give permission for Triangle, Inc. to use only the specific photographs and/or videos attached to this authorization for the purposes I select in Section III.
- I give permission for Triangle, Inc. to take photographs and/or video images of me only during the specific event(s) identified below, and to use the images/videos captured at that event for the purposes I select in Section III. This option does not authorize photography/videography of me outside of this event.
- If you check C., please fill in the event details (must be specific):
- Event name/description:
- Date(s):
- Location:
- Timeframe (if applicable):
- Note: You may check more than one option if you want to authorize (1) additional use and release of future images (A), (2) specific existing images (B), and/or (3) event-only images that will be captured at the event listed above (C) for selected purpose(s) in section III.
- If I select more than one option, I understand the purposes selected in Section III apply to all unless I list different purpose(s) or use limits for the specific image(s) or event(s) here (e.g., Photo #1: newsletter only; not social media):
- Triangle, Inc. website(s)Triangle, Inc. social media accounts (e.g., Facebook, Instagram, X/Twitter, YouTube, etc.) - NOTE: I understand that image(s) and/or video(s) posted on the internet can be viewed and downloaded by others and that social media posts may be shared or re-tweeted by other accounts once posted by the Triangle, Inc. and I hereby consent to the same.Printed materials (brochures, flyers, newsletters) - NOTE: This does NOT include marketing materials used by Triangle, Inc. which may involve Triangle, Inc. being directly or indirectly paid.Public presentations/training (community presentations, conferences, recruitment events)Internal provider communications (staff training materials, internal newsletters)Other
- A) Use without identifying information: The image(s)/video(s) may be used without my name or other identifying information.B) Use with identifying information: The image(s)/video(s) may be used with identifying information as described below:
- First name onlyFirst and last name
- 1. No requirement to consent. I understand that signing this form is voluntary, and I do not have to sign it to receive services or supports from Triangle, Inc. I understand that no punitive or negative actions will be taken against me if I do not sign this authorization or if I withdraw my consent.
  2. No private/sensitive settings or overly intrusive images. This permission does not authorize photography/videography during personal care or in private areas (e.g., bathrooms/bedrooms), or in circumstances that a reasonable person would consider intrusive, private or sensitive.
  3. No permission to use images for marketing purposes. This authorization does not permit Error!Reference source not found. to use photographs or video images of me for marketing purposes as defined by the Health Insurance Portability and Accountability Act (“HIPAA”) in 45 CFR 164.501, 164.508(a)(3).
  4. No permission to alter images. This authorization does not permit Triangle, Inc. to alter images in any way, including with the use of Artificial Intelligence (“AI”)
  5. Redisclosure. I understand that once images/videos or identifying information are shared, recipients may re-disclose them and they may not be protected by privacy laws or regulations.
- I understand I may revoke (cancel) this permission at any time by submitting a written request to:
  
  Provider Contact/Office/Title: Triangle, Inc.
  Mailing Address: 450 Broadway, Malden, MA 02148
  Email: learnmore@triangle-inc.org
  Phone: 781 322 0400
  - Revocation applies going forward only. It does not apply to uses or disclosures that already occurred before Triangle, Inc. received my written revocation.
  - After revocation, Triangle, Inc. will stop future use and will remove images/videos from Triangle, Inc.-controlled platforms where feasible but cannot guarantee removal of copies shared by others.
- This permission expires at the conclusion of _ Event name (must occur within 1 year of the date signed). If no event is listed, this permission expires no later than one (1) year from the date signed.
- Individual (or Legally Authorized Representative) Signature: *
  
  Clear
- Date*
  
  MonthDayYear
  Date
- Full Name *
  
  First NameLast Name
- If signed by Guardian/Legally Authorized Representative (“LAR”)
- Relationship to Individual
- GuardianOther
- YesNo
- Scope/limitations (if applicable):
- Please enter an email address to receive confirmation that this form was submitted successfully and a copy of this media consent.
  example@example.com
Should be Empty:

Permission for Release and Use of Photographs/Video Images - 115 CMR 5.04(2)