Hull University Teaching Hospitals NHS Trust would like your permission to use your image, name and other information relating to you for publicity purposes. Please complete this form to indicate your consent to your data being used in this way.
I (the person being filmed or photographed) explicitly grant Hull University Teaching Hospitals NHS Trust the unrestricted and irrevocable right and permission to copyright and lawfully use, re-use and publish photographs and/or videos in which I am the subject or included, in any medium, throughout the world without any restriction whatsoever as to the nature of the use or publication, whether the use or intended future use is known to me, and whether the photographs or videos are used in whole or in part for the purposes of marketing, illustration, promotion, advertising, recruitment or any other purpose, through any or all forms of media.
I understand that the images or video footage may be altered, changed or reproduced by Hull University Teaching Hospitals NHS Trust or a third party and I waive any right to inspect or approve any finished product. I understand that I do not own the copyright of the photographs or video footage and assign any rights that I may have to Hull University Teaching Hospitals NHS Trust.
I further explicitly grant Hull University Teaching Hospitals NHS Trust the unrestricted and irrevocable right to use my name, age and, if I am a patient of Hull University Teaching Hospitals NHS Trust at the time of recording, details of the care I have received under Hull University Teaching Hospitals NHS Trust alongside photographs or video in which I appear and which are the subject of this consent form.
I understand this information may appear in printed media, broadcast media and online and in formats including, but not limited to, newspaper articles, TV reports, advertisements, social media posts, promotional videos and hospital publications, and I understand it may be further shared in ways which are beyond the control of Hull University Teaching Hospitals NHS Trust.
This agreement will become effective from the day it is signed for a period of three years. I understand that my image and information may be publicly available outside of the three year period but that Hull University Teaching Hospitals NHS Trust must have made arrangements to use, publish, share, print or reproduce my photograph/video image and any accompanying information inside the three year period.
I certify that I am over 18 years of age and that I have the full legal right to execute this agreement.