Free photo release form 38
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The Johns Hopkins Hospital / Johns Hopkins University School of Medicine

Information & Photographic
Authorization/Release
Name

_________________________________________________________

Address_________________________________________________________
_________________________________________________________

I, ______________________________, hereby authorize the making of photographs,
videotape, and/or motion pictures (hereinafter “pictures) of: _________________________

_________________________________________________________
by the staff, employees or agents of the Johns Hopkins University School of Medicine and
The Johns Hopkins Hospital (hereinafter “the University”), Johns Hopkins Medical
Video/Digital Media Group.
I authorize the use of such pictures for the following purpose(s):
___

Educational Purposes

___

Medical Records

___

Media Release

___

Research

___

Publicity

___

Other ______________________________________________________________

I understand that my na