Photography/Video/Likeness Authorization & Release Form

By execution of this form, I hereby authorize Halifax Health, its affiliated companies and/or their legally authorized representatives to acquire, use and/or disclose the image, voice, written word, likeness, depictions on social media, or other representation depicting the individual(s) signed below.

I attest that information provided pursuant to this authorization is, to the best of my knowledge, complete and accurate as of the date of this Authorization. There are no special limitations as to the uses authorized, and this Authorization covers all usages and relieves all liability in connection with the use of images, voice, written word, likeness, and depictions on social media, and information provided or acquired.

I waive any right to inspect or approve the finished product, the advertising copy, or other matter containing my image, voice, written word, likeness, depictions on social media, or any other information provided or acquired. I understand that I am waiving any right to compensation from Halifax Health in association with the commercialization of the above.

I understand that Halifax Health will not condition the provision of health care services on whether or not I sign this Authorization. I understand that images or other information disclosed may no longer be protected by state or federal privacy laws or regulations and may be re-disclosed by the recipient of the information. This authorization does not have an expiration date. This Authorization may be revoked by written request to Halifax Health at the following address:

Marketing Communications

Halifax Health Medical Center

303 N. Clyde Morris Blvd.

Daytona Beach, FL 32114

I certify that I am the named individual below and that I am of age and legally competent to execute this Authorization.