Photo/video authorization form

Photo/video authorization form

"*" indicates required fields

Contact details

Name*

First Last

Pronouns*

He/Him

She/Her

They/Them

Please select the option that best describes you*

Foundation staff member

Hospital staff member

Patient/Patient parent

Sponsor

Corporate/CMN partner

Other

Business name*

Hospital unit/department*

Other*

What event/activity is your photo/video being captured at?*

Home address*

Street Address City Province Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Daytime phone*

Email*

Email consent

By clicking this box, I give my expressed consent to receive electronic news and information from the Stollery Children’s Hospital Foundation.

I agree photos/videos provided to and/or captured by the Stollery Children’s Hospital Foundation may be used now or in the future for the purpose of: (please check all that apply)*

Website and social media promotion – on the Foundation website(s) and/or social media platforms (including but not limited to: Twitter, Facebook, Instagram, YouTube, stollerykids.com)

Partner/affiliate publication/promotion – can be shared with our affiliates such as the Stollery Children’s Hospital, Alberta Health Services, Women and Children’s Health Research Institute, the University of Alberta, Canada’s Children’s Hospital Foundations

All – can be used for Foundation promotional purposes including, but not limited to website/social media promotion, shared with affiliates and mass media opportunities

Should a large-scale/mass media marketing opportunity arise, every attempt will be made to gain permission and notify you prior to sharing your photo(s)/video(s).

This completed waiver form applies to the following individual(s):*

Please include your name as well as the names of any individuals who are minors that this completed waiver form covers.

Signature*

Date*

MM slash DD slash YYYY

Please include a brief description of the person in the photo/video to enable us to match your consent to this individual. (eg. clothing colours/symbols, hair colour, glasses, etc.):*

Additional notes

Feel free to include any any additional details surrounding your photo/video sharing permissions.

Submit

Thanks for supporting Stollery kids!