Full name

Address

For what purpose are you granting permission to Roper St. Francis Health to take your photograph and/or video?

I do hereby release Roper St. Francis Healthcare, its successors, assigns, and all persons working under the organization’s authority from any liability whatsoever that might occur as a result of the taking, use, or publication of my photograph(s) and/or video.

Electronic signature

Date

Open the calendar popup.

Time

FOR MINORS, COMPLETE THE FOLLOWING:

Father, Mother or Guardian Name

Address

Are you the father, mother or guardian?

Father
Mother
Guardian

Minor's name

I have read the above and do consent to all the provisions of such agreement on behalf of the minor listed above.

Yes
No

Electronic signature

SUBMIT