Publicity Consent Form

I hereby authorize the use and reproduction of photographs, films, videotapes, interviews and information about me taken by or for Baptist Memorial Health Care Corporation or any affiliated corporation or entity (hereinafter collectively called “Baptist”) and/or its agent for use in publicity and promotion, including reproduction of my likeness, voice and sound effects in radio, television, videotape, internet, film and print media without limitations or reservations. I also authorize the use of my name without any reproduction. I further agree that should BMHCC choose to use my likeness or voice and sound effects, the sole property interest in the likeness, voice and sound effects as retained on whatever type of medium becomes vested in Baptist.

First Name

Last Name

First Name of parent or guardian (if applicable)

Last Name of parent or guardian (if applicable)

Reason for Consent

Topic Discussed

Question / Comment

Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

I understand this authorization is completely voluntary on my part. The authorization in no way affects my employment, employment status, pay or any other employment-related benefits with any Baptist affiliated entity. This authorization shall remain valid for so long as Baptist maintains the images and/or information described above. I understand I have the right to revoke the authorization, but that if I wish to do so, I must communicate my desire in writing to the Corporate Communication Office of Baptist Memorial Health Care Corporation. I understand that the images and/or information described above will not be considered private or confidential because I have authorized their use in a public forum.

I have read and agree to above terms