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NUIC is a coalition of community members desiring to improve the health of northern Utah through increasing immunization rates. Current membership is made up of parents, physicians, nurses, employees of the Utah Department of Health, Davis County Health Department, Weber/Morgan County Health Department, Bear River Health Department, Long-term care facilities, Community Nursing Services (CNS), Vaccine Manufactures, school districts, and other representatives from local Clinics and Hospitals.
The Northern Utah Immunization Coalition is seeking permission to use an image of you or your child/dependent. By signing this release, you are authorizing NUIC to use your or your child’s image according to these terms. The image may be used on the NUIC’s Web site, promotional brochures or publications, such as its monthly newspaper, or other media, to promote public health or the coalition. The NUIC will not use the image in a way that defames or misconstrues the subject and will not use the image for profit or resale.
ADULT RELEASE AUTHORIZATION
I hereby give the Northern Utah Immunization Coalition permission to publish in print, electronic or video format my likeness or image for purposes of promoting public health or the NUIC. I release all claims against the NUIC with respect to copyright ownership and publication including any claim for compensation related to the use of the materials. I hereby hold the NUIC harmless from any claims, demands or causes of action I or other persons acting on my behalf may have by reason of this authorization. In addition, I waive the right to inspect or approve any finished product including written or electronic copy wherein my likeness appears.
Signed: Date:
Printed name: ___________ Date:
CHILD OR MINOR RELEASE AUTHORIZATION
I hereby give the Northern Utah Immunization Coalition permission to publish in print, electronic or video format the likeness or image of my child for purposes of promoting public health or the NUIC. I release all claims against the NUIC with respect to copyright ownership and publication including any claim for compensation related to the use of the materials. I hereby hold the NUIC harmless from any claims, demands or causes of action I or other persons acting on my behalf may have by reason of this authorization. In addition, I waive the right to inspect or approve any finished product including written or electronic copy wherein my child’s likeness appears.
Child’s name: _ Date:
Your name (parent or guardian, please print): ________
Your signature:
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