Consent and Waiver

Consent and Waiver

To Whom It May Concern:

I hereby grant permission to the University of Maryland School of Nursing to reproduce and use my picture, portrait, likeness or voice in connection with the production of a still photograph, website photograph, motion picture, television tape, sound recording, or any other communication media for any and all educational, research and marketing purposes the University deems necessary to further its goals of teaching, service, and research.

I hereby waive all rights of privacy or compensation, which I may have in connection with the use of the above-mentioned material for any of the said purposes. Further, I hereby waive my right to inspect or approve the finished product and I discharge the Board of Regents, the University of Maryland, and their agents and employees from any liability by virtue of use of the above-mentioned material.

I further release and discharge the University of Maryland School of Nursing from any other claim or payment of royalties by virtue of the use of the said material.

I understand the above statement.

Please print.

DATE: EVENT/PURPOSE:

NAME : _________________________________________________________

ADDRESS: ______________________________________________________

CITY, STATE, ZIP: ________________________________________________

EMAIL: _________________________________________________________

PHONE: ________________________________________________________

SIGNATURE: _____________________________________________________