Full name
Address
For what purpose are you granting permission to Roper St. Francis Health to take your photograph and/or video?
I do hereby release Roper St. Francis Healthcare, its successors, assigns, and all persons working under the organization’s authority from any liability whatsoever that might occur as a result of the taking, use, or publication of my photograph(s) and/or video.
Electronic signature
*
Date
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FOR MINORS, COMPLETE THE FOLLOWING:
Father, Mother or Guardian Name
Address
Are you the father, mother or guardian?
Father
Mother
Guardian
Minor's name
I have read the above and do consent to all the provisions of such agreement on behalf of the minor listed above.
Yes
No
Electronic signature
SUBMIT