Authorization and Consent to Photograph and Publish

The undersigned hereby authorizes the UC Simulation Center at the University of Chicago and attending physician to photograph or permit other persons to photograph participants and simulation staff undergoing simulation experiences at the Center. The undersigned agrees that the University and the attending physician may use and permit other persons to use the negatives, prints, videotape or films prepared from such photographs for the purposes and manner as either may deem appropriate. The undersigned agrees the photographs may be used for purposes including, but not limited to, dissemination to the hospital staff, physicians, health professionals, members of the public for educational, treatment, research, scientific, public relations, advertisement, promotional and/or fund raising purposes, and that such dissemination may be accomplished in any manner. Such use is subject only to the following limitations:

■ Only still photographs and brief video clips will be shared outside the Center’s research and instructor teams without previous visual check of such materials by the individuals shown.

■ Individuals may be asked to view and approve the specific usage of videos longer than two minutes and have the opportunity to refuse.

■ If individual(s) refuse, the Center may use technology to blur out faces and other features which could allow the individual to be recognized.

The undersigned has entered into this agreement in order to assist scientific treatment, education, public relations, promotional and/or fund raising goals and hereby waives any right to compensation for these uses by reason of forgoing authorizations, and the undersigned and his or her successors, hereby hold the hospital and University and attending physician and their successors, harmless from and against any claim for injury or compensation resulting from the activities authorized by this agreement. The term “photograph” as used in this agreement, shall mean motion picture or still photography in any format, as well as videotape, video disc and any other mechanical means of recording and reproducing images.