LifeShare Carolinas

Permission to Use Likeness

This form gives us permission to use yours or your loved one's stories, image, voice, etc. under intellectual property laws. It is separate from the Authorization, which gives us permission to use and disclose your information under patient privacy laws.

I grant The Charlotte-Mecklenburg Hospital Authority d/b/a LifeShare Carolinas and its associated foundations, even if separately incorporated, a perpetual, worldwide, royalty-free license and permission to record, use, disclose, portray, reproduce, broadcast, stream, post, print, and publish my (or the person on whose behalf I am serving as a personal representative, who will be included in the terms “my”, “me”, “mine”, or “I”) likeness, picture, video, information (including that released pursuant to an Authorization), story, quotes, and interview, whether in digital, electronic, paper, print, video, oral, or televised form (“Information”) for LifeShare Carolinas’ current or future internal and external marketing, fundraising, public relations, and educational purposes on behalf of LifeShare Carolinas (including on behalf of its programs and associated foundations).

I understand that such information will be the exclusive property of LifeShare Carolinas, free and clear of any claim on my part and may be used in future video or print projects, in whole or in part. I understand that I will not be compensated for the permissions, licenses, or use of the Information. I also understand that LifeShare Carolinas is only responsible for its own actions, and does not control third parties, including other media outlets. I understand that I can request that production of the recording be stopped at any time during production and I can revoke this Permission before the Information is used. On behalf of myself, my child, our heirs, and representatives, I agree to release LifeShare Carolinas, their commissioners, directors, officers, and employees, from and against any liability related to their use of the Information.

NOTE: If the person lacks legal capacity, is unable to sign, or is a minor, an authorized personal representative may sign this form. Note the relationship/authority if signing on behalf of someone.

Patient/Minor's Name:  

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Signature Certificate
Document name: Permission to Use Likeness
lock iconUnique Document ID: 31aa22af4b5755a942394a16ceee199af9abd526
November 28, 2022 9:45 pm PDTPermission to Use Likeness Uploaded by Kate McCullough - IP