KRH Photo/Video Consent Form

Please fill out this form completely. Once submitted, this form will be kept on file in the Marketing department at Kalispell Regional Healthcare. If you have any questions, please contact Dustin Jones at

I do hereby, being of legal age, consent to the use of my name, picture, silhouette, caricature, video/film reproductions of my physical likeness, and/or verbal statements in print and/or audio reproduction in the marketing communications programs of Kalispell Regional Healthcare (KRH). This includes my personal story, but does not include any details of care received at KRH. Any materials that I have submitted are not under obligation to another party. I hereby release Kalispell Regional Healthcare from any liability resulting from said marketing communications programs. I have entered into this agreement to assist KRH with marketing, public relations and charitable goals and hereby irrevocably waive any right to compensation for such uses.

This is my electronic signature. I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

Enter Your Full Name

Complete this section if you are a parent/guardian signing on behalf of a minor.

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