UNT Health Photo Permission, Waiver, and Release

The University of North Texas Health Science Center at Fort Worth

Media Release Form

I hereby authorize The University of North Texas Health Science Center at Fort Worth and its agents,

employees, licensees, or assigns (collectively, the “University”) the absolute right, authority and permission to:

Record my likeness on video, audio, photograph in digital or any other medium; use my name in connection

with these recordings; use, reproduce, exhibit or distribute the recordings for any purpose that University, and

those acting pursuant to its authority, deem appropriate, including promotional or advertising efforts, in any

medium, now available to University and that may be available in the future, including but not limited to print

publications, newspapers, magazines, radio, television, video or other electronic/online media.

I release, and hereby agree to indemnify, defend, and hold harmless the University, its agents, employees,

licensees, and assigns (the “Released Entities”) from and against any and all claims that I, or any third party,

may have now or in the future for invasion of privacy, right of publicity, copyright infringement, or defamation

arising out of the publication, use, exploitation, reproduction, adaptation, distribution, or broadcast of my

likeness.

I understand that all such recordings, in whatever medium, shall remain the property of University, and I

further understand and agree that I am to receive no compensation of any kind, monetary or otherwise, on

account of or arising from the production, publication, recording, rebroadcasting or other such use of

recordings.

I am of full legal age and competent to contract in my own name. I have read this Media Release and am fully

familiar with its contents and the meaning and impact thereof and agree to be bound by its terms.

By checking this box, I’m agreeing and acknowledging this waiver and release.

By checking this box, I’m declining to sign this waiver and don’t want my photo taken.

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(Participant Signature)

________________________________

(Printed Name)

_________________________________

(Date)

_________________________________

(School / Department)

_________________________________

(Role, i.e. Student / Staff / Faculty / Community

Member

_________________________________

(Participant Email)

_________________________________

(Participant Phone)

_________________________________

(Notes / Special Project)

Consent of Parent or Guardian

(applicable if Participant is under 18 years of age or requires a guardian)

I am the parent of the minor individual named above, or the legal guardian of the

individual named above. I am at least 18 years of age, and I have the legal authority to execute

this Multimedia Waiver and Release on the Participant’s behalf. I approve and agree to the

terms and conditions as set forth above.

Parent/Guardian signature:

Printed Name:

Date:

MEDIA RELEASE Page 1 of 1

UNTSYSTEM-OGC APPROVED 05/07/24 - 06/01/2026

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