Purpose
Semmes Murphey Clinic, P.C. (“Semmes Murphey”) occasionally creates photographs, videos, and other media (“Media”) for educational, promotional, and public relations purposes. Your child has been invited to participate in one of these productions. Please review and sign below to authorize Semmes Murphey to record and use your child’s image, voice, and likeness.
1. Consent and Grant of Rights
I, the undersigned parent or legal guardian, hereby grant Semmes Murphey Clinic, its employees, agents, contractors, representatives, licensees, and assigns (collectively, “Semmes Murphey”) the irrevocable right to:
Record, photograph, videotape, and/or otherwise capture my child’s image, likeness, voice, and statements (the “Media”);
Edit, modify, or combine the Media with other materials; and
Use, publish, broadcast, display, reproduce, and distribute the Media, in whole or in part, in any medium now known or later developed, including but not limited to printed materials, digital platforms, websites, social media, and other public communications.
This consent applies solely to general media use. Participation is voluntary and unrelated to any current or future medical care at Semmes Murphey Clinic. No medical information will be collected, used, or disclosed as part of this media activity.
2. No Compensation
I understand that my child’s participation is voluntary. My child and I will not receive any compensation, payment, or royalties for participation or for the use of the Media now or in the future. I waive any right to inspect or approve the finished Media or its use.
3. Ownership and Release
I acknowledge that Semmes Murphey will own all rights, including copyright, in the Media. I release and hold harmless Semmes Murphey and its employees, agents, contractors, and representatives from any and all claims, demands, or causes of action arising from or related to the use of the Media, including claims for invasion of privacy, right of publicity, or defamation.
4. Acknowledgment of Non-Patient Status
I understand and acknowledge that:
My child is not participating as a patient in this media activity;
The Media will not include any health information or suggest the child is receiving medical treatment; and
Semmes Murphey will not associate this recording with any medical record or patient file, even if my child becomes a patient in the future.
This Media Release is separate from any patient authorization and does not grant permission to use any protected health information (PHI).
5. Duration and Revocation
This consent is perpetual and irrevocable. I understand I may withdraw consent before recording occurs by notifying Semmes Murphey in writing. Once Media has been created, I understand withdrawal is no longer possible.
6. Governing Law
This agreement shall be governed by and construed in accordance with the laws of the State of Tennessee.