Media Release Authorization

I understand that an image, photograph, video, and/or a sound/audio recording (“Media”) of me may be taken or made by Sparrow Health System, on behalf of itself, its affiliates, subsidiaries, employees, agents, and/or persons acting under their authority or direction (“Sparrow”). I hereby grant permission for Sparrow to make, reproduce, copy, exhibit, publish, distribute, and otherwise use for publicity, fund raising, advertising, or any other lawful purpose such Media. I hereby release and discharge Sparrow, its officers, agents, representatives, and all persons acting under their authority or direction from all liability of any nature whatsoever arising from their use of said Media. Furthermore, I assign all right, title, and interest I may have with respect to such Media to Sparrow. No payment or consideration will be due to me related to the Media.

I understand that this authorization may be revoked by me at any time except to the extent action has been taken in reliance upon it. Furthermore, I understand that this authorization will remain in effect indefinitely unless specifically revoked by me. Revocation must be made in writing to Sparrow Health System, Attn: Marketing, 2900 Hannah Boulevard, Suite 201, East Lansing, MI 48823. 

Consistent with Sparrow policies, I agree that I will not disparage, defame, or damage the reputation, or cause or tend to cause the recipient of a communication to question the business condition, integrity, competence, good character, professionalism, or service/product quality of or otherwise speak or write negatively about Sparrow, its employees, agents, or affiliates or cause any other person to disparage or speak or write negatively about Sparrow, its employees, agents or affiliates. This non-disparagement clause shall survive any revocation of the media release authorization contained herein. 
I understand that an image, photograph, video, and/or a sound/audio recording (“Media”) of me, may be taken or made by Sparrow Health System, on behalf of itself, its affiliates, subsidiaries, employees, agents, and/or persons acting under their authority or direction (“Sparrow”). I hereby grant permission for Sparrow to make, reproduce, copy, exhibit, publish, distribute, and otherwise use for publicity, fund raising, advertising, or any other lawful purpose such Media. I hereby release and discharge Sparrow, its officers, agents, representatives, and all persons acting under their authority or direction from all liability of any nature whatsoever arising from their use of said Media. Furthermore, I assign all right, title, and interest I may have with respect to such Media to Sparrow. No payment or consideration will be due to me related to the Media.

I understand that this authorization may be revoked by me at any time except to the extent action has been taken in reliance upon it. Furthermore, I understand that this authorization will remain in effect indefinitely unless specifically revoked by me. Revocation must be made in writing to Sparrow Health System, Attn: Marketing, 2900 Hannah Boulevard, Suite 201, East Lansing, MI 48823.
I understand that the story, image, photograph, video, and/or a sound/audio recording (“Media”) of me may contain information relating to my diagnosis, treatment, and health care services provided or to be provided by Sparrow and identifies my name and other personally identifiable information. I hereby grant permission for Sparrow to make, reproduce, copy, exhibit, publish, distribute, and otherwise use for publicity, fund raising, advertising, or any other lawful purpose such Media. I hereby release and discharge Sparrow, its officers, agents, representatives, and all persons acting under their authority or direction from all liability of any nature whatsoever arising from their use of said Media. Furthermore, I assign all right, title, and interest I may have with respect to such Media to Sparrow. No payment or consideration will be due to me related to the Media.

I understand that any personal health information or other information released by Sparrow may be subject to redisclosure by others and may no longer be protected by applicable federal and state privacy laws.

I understand that this authorization may be revoked by me at any time except to the extent action has been taken in reliance upon it. Revocation must be made in writing to Sparrow Health System, Attn: Marketing, 2900 Hannah Boulevard, Suite 201, East Lansing, MI 48823. This authorization will remain in effect until:
Sign above
To be completed if the person identified above is under age 18.
To be completed if the patient identified above is under age 18 or legally incapacitated.
I hereby certify that I am the parent, guardian or (print relationship)