Office of Minority Health
Authorization, Release, and Clearance
Authorization to Use Photographs and/or Audio-Visual Recordings I hereby grant the Office of Minority Health (OMH),U.S. Department of Health and Human Services (HHS) permission to use, reproduce, or publish my image, likeness, or voice without compensation or any other consideration, in photographs and/or video for purposes of advancing OMH?s mission and publicizing its programs and initiatives and for any other lawful purpose.
I understand that these photographs and audio-visual recordings are the property of OMH and will not be returned. I also understand that these photographs and audio-visual recordings will be in the public domain and OMH may further reproduce, edit, alter, copy, exhibit, publish, or distribute these photographs and audio-visual recordings without further permission.
I waive the right to inspect or approve the finished product, including any written or electronic copy, wherein my image, likeness, or voice appears. In addition, I hereby hold harmless and release and forever discharge OMH and HHS from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
I have read this authorization before signing below and I fully understand the contents, meaning, and impact of this authorization.
_____ OMH MAY use my real name.
If the person signing is a minor, there must be consent by a parent or guardian, as follows:
I hereby certify that I am the parent or guardian of ________________________, named above, and do hereby give my consent without reservation to the foregoing on behalf of this person.