Speaker Name: Credentials

CME Photography/Video/Audio Agreement and Release

Speaker Name: Credentials: Activity Title: Location of Activity: Date:

Photography / Video / Audio Agreement and Release I, as the Subject, grant to Florida Hospital a perpetual, irrevocable and unrestricted right to use, reuse, publish and re-publish photographic portraits or pictures, digital images, slides, movies, video tape footage and/or other media coverage of the Subject, including the Subject’s face and/or image (the “Image”), in which the Subject may be included in whole or in part, whether as a composite or distorted in character or form, with the Subject’s own name or a fictitious name for the following project: Place Event Name here. This right to use the Image shall extend to any reproductions in color or black and white, made through any medium and in any and all media now or hereafter known, whether used by itself or with printed material and/or other accompanying material, for any purpose, regardless of the way the Image is transmitted.

The Subject waives any right to inspect or approve the finished product or products and/or the advertising copy or other matter containing the Image. The Subject further waives any right to compensation received by Florida Hospital in association with the commercial use of the Image.

THE SUBJECT RELEASES AND AGREES TO HOLD HARMLESS FLORIDA HOSPITAL, ITS EMPLOYEES, OFFICERS AND AGENTS, FROM ANY LIABILITY ASSOCIATED WITH THIS GRANT, INCLUDING ANY CLAIMS FOR LIBEL OR INVASION OF PRIVACY.

For purposes of this agreement and release, the term “Florida Hospital” shall include all business entities which are now or in the future owned or controlled or managed by Florida Hospital and those business entities which are or subsequently become subject to the common control or ownership of an organization which owns or controls Florida Hospital.

I warrant that I am over the age of 18 and have the right to contract in my name. I have read and understand the content of this release. This release shall be binding upon the Subject, his/her heirs, legal representatives and assigns.

The laws of the State of Florida shall govern this agreement and any disputes arising out of it.

Print Name: Print Name Signature: ______

Address: Insert Address

Phone Number: Phone Number Date: Date Return SIGNED form to Virginia Provenza CME Coordinator 2501 N. Orange Avenue Suite 233, Box 38 Orlando, FL 32804 Office: (407) 303-2858 Fax: (407) 303-3273

2018 年 5 月 7 日 www.FHCME.com 1