I, , hereby
agree to grant to Montefiore Medical Center and Albert Einstein
College of Medicine, its successors and all
persons acting under its permission or authority including, but
not limited to, its employees and agents (collectively,
"Montefiore and Einstein") permission to photograph, publish,
reproduce, record and use photographs, motion pictures,
videotapes or audio tapes (collectively referred to as "Images")
of me (or my child, [INSERT NAME]), in order to memorialize the
medical care, surgery, any other procedures to be performed, my
presence at Montefiore and Einstein facilities, and/or
participation at Montefiore and Einstein events. The Images may
be used for any and all purposes, including but not limited to
distribution to the media, educational, promotional, publicity,
advertising and fundraising purposes, as well as for possible
publication by Montefiore and Einstein in various traditional and
social media (e.g. Facebook) and on the internet. I acknowledge
and agree that neither Montefiore nor Einstein will pay me (or my
child) in any manner for such photographing/ recording and use of
the Images. I grant this permission and release as a voluntary
contribution and I waive any and all rights I(or my child) may
have to royalties or other compensation in connection with any
such publication or use. I hereby waive my right to inspect
and/or approve the finished products and final usages
I hereby release and discharge Montefiore and Einstein from
any liability by virtue of any blurring, distortion, alteration,
optical illusion or use in composite form that may occur or be
produced in the creation or processing of any images created by
Montefiore and Einstein. The foregoing permission is granted for
the entire time period during which I (or my child) receive(s)
outpatient and inpatient treatment at Montefiore or Einstein and
the right to use the Images shall continue until such time that
the footage, photographs and other images are no longer used by
Montefiore or Einstein for educational, promotional, publicity,
commercial and fundraising purposes. I also understand that I may
contact my attending physician in writing to revoke future uses,
but that my revocation will not affect disclosures of information
that have already occurred. I understand that I am not required
to sign this form authorizing the use of Images, and I may refuse
to do so without any effect on my receipt of care at Montefiore
I hereby release Montefiore Medical Center and Albert
Einstein College of Medicine, its trustees,
officers, employees, physicians, agents and assigns from any and
all legal liability that may arise from any of the foregoing and
I waive any and all rights I (or my child) may have to royalties
or other compensation in connection with any of the foregoing.