Photo Consent Form

I, hereby authorize the duly appointed representative of Regional West or designated agent to interview me and to take such recording, film, or photograph of me on behalf of Regional West Foundation. I understand the purpose of the use of my name, recording, film, or photographs. I further understand that I have the right to request the recording, film, or photography be stopped at any time while it is occurring, and that I have the right to rescind consent for the use up until a reasonable time before the media is used. I agree to hold Regional West, providers, staff, and agents free and harmless from any and all liabilities, costs, damages, or ill effects that might arise from the expansive use or publication of any use of my name, recording, film, photograph, or other information made in accordance with this Consent. I understand this Consent shall be valid until informing Regional West in writing of my intent to revoke. I understand that a recording, film, photograph, or information made pursuant to this Consent may not be protected by federal privacy rules if further disclosed. I will not take or distribute video, recordings, or photographs of any Regional West employee or provider without their consent.