Consent to Photograph/Video/Publish

Consent to Photograph/Video/Publish
I give Aspirus Health and its affiliates permission to utilize:
Aspirus Health and its affiliates have my permission to use the above for:
Description (give as much detail as possible):
Use restriction (indicate if applicable):
This consent is irrevocable unless revoked by mutual agreement between the subject and Aspirus Health. I have read and understand this irrevocable release.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Name of Person Giving Consent:

First NameLast Name
Signature:
Name Parent/Guardian (if minor):

First NameLast Name
Signature of Parent/Guardian
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Name of Aspirus Health Witness

First NameLast Name
Signature of Aspirus Witness
Should be Empty: