Media Consent Form

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* 1. First Name

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* 2. Last Name

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* 3. I consent to having one or more of the following done for the purpose of Ornge’s media releases and communications (please check all that apply):

Interviewed for my personal story (including my personal information, provided in a level of detail that is at my discretion to disclose to the interviewer)

Photographed

Videotaped

Audiotaped

Other (please specify)

I give my permission to Ornge, and its group of related companies, to take, produce and/or collect information, photographs, films, sound recordings and any other audio and/or visual reproductions of myself for the purposes of using my image, recording or information in any manner, including but not limited to use by:

Ornge in its materials such as books, videos, posters, pamphlets, brochures, intranet site and/or website; and
External media such as newspapers, TV news programs and/or radio programs.

I understand and consent to my image, recording or information, as the case may be, being maintained and used in the Ornge archive of media releases and communications.

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* 4. In any of the above described publications (please indicate your preference):

I give consent to using my name.

I give consent to using my initials only.

I do not consent to use of my name or initials.

I acknowledge that whether or not Ornge provides my name to the media, a member of the media, or a member of the public may be able to identify me through means independent of Ornge. If that occurs, I shall not hold Ornge responsible on any basis for the disclosure of my identity.

I acknowledge that the image, recording or information used on the internet or by external media reside in the public domain, and as such I shall not hold Ornge accountable for any subsequent use.

I understand, acknowledge and hereby waive any and all claims for payment arising from any use made of my image, recording or information.

I acknowledge that I may refuse to give consent, and that withholding my consent will not impact upon the treatment and transportation services Ornge may deliver, nor will it impact upon my employment relationship with Ornge, as the case may be.

By signing below, I authorize Ornge to collect, use and disclose my image, recording or information as it may deem fit for the purpose of Ornge’s media releases and communications and other similar, consistent purposes.

Media Consent Form

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. I consent to having one or more of the following done for the purpose of Ornge’s media releases and communications (please check all that apply):

Question Title

* 4. In any of the above described publications (please indicate your preference):

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* 5. Signature

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* 6. Date

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* 7. Project