I permit the University of Michigan School of Public Health (SPH) or its representatives to record a photographic image
Consent to Photograph or Record Electronically Name: ______________________________________________________________________ (please print)
Event: ______________________________________________________________________ (please print)
I permit the University of Michigan School of Public Health (SPH) or its representatives to record a photographic image and/or audio/video of me for educational or research purposes, or for promotional purposes associated with the mission of the School of Public Health, the University of Michigan, and SPH departments, programs, centers, and institutes. The School or its representatives may, at their sole discretion, publish or distribute these photos or recordings for official purposes, in materials or channels sponsored by the School or by the University of Michigan. Such materials and channels may include, but are not limited to: print publications, websites, social media, apps, video presentations or streams, podcasting, advertising, or broadcast media. I understand that the pictures and recordings are the property of the School, and that I will not receive payment, compensation, or additional notification in connection with the photos or recordings, or their future uses. I have had the opportunity to review this form and to ask any questions of a SPH or University representative. I release the U-M School of Public Health and the University of Michigan from any and all liability that may or could arise from the creation or use of the photos / recordings. I certify that I am at least 18 years of age, and am fully able to grant consent to be photographed / recorded. Signature: ___________________________________________________________________ Date: _______________________________________________________________________ Street Address: _______________________________________________________________ City, State, Zip: _______________________________________________________________
(Admin:) Project for which images are needed: ______________________________________ U-M SPH project representative and phone number / e-mail: ____________________________________________________________________________ 1415 Washington Heights Ann Arbor, MI 48109-2029
734-763-4523 sph.umich.edu
