Release & License of Image, Name and/or Audio Record

(for commercial use of image, name, audio record)

AUDIO/VISUAL SUBJECT INFORMATION

First Name:

Last Name:

Date of Birth:

MM/DD/YYYY

If Subject is under 18 years or lacks capacity, please provide name of parent/guardian and relationship to Subject.

SelfLegal Representative

First Name of Legal Representative:

Last Name of Legal Representative:

Relationship to Subject:

Street Address:

City:

State:

Zip:

Telephone Number:

This Release & License for Use of Image, Name and/or Audio Record (“Consent”) is between You and Westchester Medical Center (“WMC”).

Under the terms of this Consent:

You consent to the creation, use, exploitation, adaptation, modification, reproduction, distribution, and/or public display, in any form now known or later developed (the “Use”), of photographic, video, film, or other visual images or graphical depictions, likeness, audio recordings, voice recordings, name, and/or biographical information of Subject, as further described below, (“Subject Material”) by Westchester Medical Center, its subsidiaries, affiliates, personnel, contractors, or any person or entity authorized by WMC (“WMC Representatives”). You waive any right to inspect or improve the finished version of Subject Material.

You understand, agree and consent that, unless otherwise indicated in writing, Subject may be identified by name or other identifying characteristic in connection with any Use of Subject Material.

Additionally, You understand and agree that WMC is and will continue to be the exclusive owner of all right, title, and interest, including copyright, in the Subject Material and hereby grant WMC a worldwide, exclusive right to Use, market and license Subject Material:

for purpose of any nature, including without limitation, for advertising, publicity, promotions, marketing, corporate communications, press articles, press releases, brochures, reports, programs and films; orOther

For the following purpose

You understand that if Subject is a patient of Westchester Medical Center or its affiliates, information regarding Subject’s medical treatment, mental health and social problems might be disclosed to the extent You have allowed in a separate consent form.

You release, and hereby agree to indemnify, defend, and save harmless, WMC Representatives, and their respective governing bodies, officers, agents, appointees, students, employees, and medical and nursing staff from any and all claims, You, Subject and/or any third party may have now or in the future resulting from the Use of Subject Material by WMC Representatives, including but not limited to any resulting release of private and personal medical and mental health and social information concerning You and/or Subject and respective families. WMC Representatives are not responsible for the release by third parties to whom any WMC Representative discloses information pursuant to this Consent.

You do hereby waive any and all rights You and/or Subject, may have to the Subject Materials and royalties or other compensation in connection with the Use of the Subject Materials.

You will have the right to revoke this Consent at any time, except to the extent that WMC Representatives have already taken action based upon this Consent and to the extent that Subject Material has already been distributed and no longer under the control of WMC Representatives. You acknowledge and agree that Your revocation or termination of this Consent will not prohibit the further disclosure of Subject Material by third parties in possession of Subject Materials. To revoke this Consent, please write to the Senior Director of Marketing at WMC.

Unless revoked by You, this Consent shall remain valid for a period of five years.

This Consent is voluntary. By signing below, You acknowledge that You have read and accept all of the above.

E-Signature

I understand that my electronic signature below has the same force and effect as my written signature.

Your Signature

Date