AUTHORIZATION AND CONSENT TO PHOTOGRAPH OR FILM AND USE IMAGES

The undersigned hereby authorizes My Baby Donor Agency, LLC (MBDA), or its designated agents, to photograph/film patients/person named below. The undersigned also agrees to images derived from such photographs/film may be disseminated to IDSA staff, physicians, affiliated health professionals and members of the public for educational, treatment, research, scientific and/or charitable purposes. Such dissemination may be accomplished in any manner deemed appropriate by MBDA, subject only to the following limitations:

The undersigned has entered into this agreement in order to assist IDSA scientific, patient care, educational, marketing and/or public relations activities and hereby waives any right to additional compensation for these uses by reason of the foregoing authorization. The undersigned may revoke this authorization at any time, but only by written notice to IDSA. IDSA shall have a reasonable time, in no event less than thirty (30) days from receipt of said notice, to cease using the images.
The undersigned waives any right to inspect or approve the images, or the method of their use, prior to their use.
The undersigned and members of his or her family, and successors or assigns hereby release IDSA its employees and physician(s), and any other person affiliated with IDSA from and against any claim for injury or compensation resulting from the activities authorized by this agreement.
The term “photograph” and “film” as used in this agreement shall mean motion picture or still photography in any format, as well as videotape, and any other mechanical means of recording and reproducing images.

If a minor child’s images are included in this Authorization/Release, include the following;

The undersigned consents to the use of the images of the minor HRC Fertility or its agent