Media Consent and Release Authorization

You are agreeing to this form to indicate that Dartmouth-Hitchcock (D-H) has your consent to interview and/or record in any format. I hereby consent to be videotaped, photographed, recorded and/or interviewed by Dartmouth-Hitchcock (“D-H”), comprised of Mary Hitchcock Memorial Hospital and Dartmouth-Hitchcock Clinic, or its authorized representative, in connection with the Simulation-Based Education and Research (SBER) initiative(s) described below:

I grant D-H the right to use and publish any such videotapes, photographs, motion pictures and/or information obtained from interview(s) (the “Materials”) in the following media (check all that apply):

I hereby waive any action I may have for payment or royalties in connection with any exhibition, televising, or publication of the Materials. I grant D-H the right to store, reproduce, distribute, publish, and display the Materials, and the right to create derivative works from the Materials, edit or modify the Materials, and use such Materials for any D-H initiative or activity consistent with the SBER initiative described above. In the event, however, that I request D-H discontinue use of the Materials in the future, D-H will try its best to accommodate my request, but I understand that D-H cannot guarantee that it will be able to do so. By signing this form, I release D-H, its subsidiaries and affiliates, and its officers, directors, trustees, employees, members, managers, agents and other representatives from all claims and demands arising out of or in connection with any use of the Materials, including, without limitation, all claims for invasion of privacy, infringement of my right of publicity, defamation, and any other personal and/or property rights. I have read and fully understand this form, and all my questions have been answered.