I hereby authorize and permit Nyack Hospital or it's authorized agent, without compensation therefore, permission to photograph, publish, reproduce, record and use, with or without my name or the name for whom I am the parent or guardian, photographs, motion pictures, video tapes or audio tapes of me or the person for whom I am parent or guardian.
I have been informed of the purpose of the photography and/or filming. I have the right to cessation of recording or filming at any time.
I have a right to rescind consent for such photography/ filming up until a reasonable time before recording or film is used. I have the right to view the photgraph or film before its publication or broadcast and have the right to withdraw consent at anytime.
Any limitations which I may want to place on the Hospital's use of these photographs/video images is noted below: