Consent for Video/Audio Recordings & Photographs for Volunteers

Consent for Video/Audio Recordings and Photographs

Elon University Department of Physical Therapy Education

Volunteer Form

The Department of Physical Therapy Education (DPTE) at Elon University is committed to the highest standards in teaching and research. Knowledge and understanding in Physical Therapy are often greatly enhanced when the abstractions in instructional content are supplemented with real and recorded examples of actual human behavior. Audiovisual materials such as videotaped sessions and photographs provide an invaluable resource of feedback for participants and a powerful learning opportunity for an examination of physical therapy techniques.

The Elon University Department of Physical Therapy Education uses such recorded material strictly for educational purposes and seeks always to avoid embarrassment for participants and disclosure of personal information. Our mission is for use of recorded materials in an ethical and responsible manner that does not violate the trust between client/volunteer and practitioner.

While DPTE will work diligently to protect participant identities, in some cases it is not possible to maintain complete anonymity. For that reason, and to clearly record your wishes with respect to the use of your visual image, we ask that you complete the attached consent form. While we would, of course, welcome your willingness for DPTE to use the tapes/photographs responsibly in all settings listed, we have listed settings separately to ensure that we understand your preferences clearly.

Please ask any questions you may have about the form to the DPTE representative.

Thank you for your support of our educational mission.

Department of Physical Therapy Education

Photographs & Video/Audio Recording Consent and Release Form

____________________________________________

Printed Name of the Client or Standardized Patient

I hereby authorize, without reservation or restriction, the School of Health Sciences at Elon University to publish the photographs or videos taken of me (while serving as a Client or Standardized Patient), and my name, for use in printed publications and website.

I hereby give the School of Health Sciences at Elon University permission to use and reuse, publish and republish, pictures of myself, in whole or in part, individually or with other photographs, in any medium for any purpose whatsoever, including (but not limited to) illustration, advertising and promotion of Elon University and programs associated with the university, or to promote the university through outside publishers.

I further agree that my participation in any publication and website produced by the School of Health Sciences at Elon University confers upon me no rights of ownership, and waive any right to compensation for the uses.

I release the School of Health Sciences at Elon University, its contractors and its employees from liability for any claims by me or any third party in connection with my participation.

Check all that you consent to:

Yes   No

___   ___ Class use for which I have volunteered.

___   ___ Other classes for which I have not volunteered.

___   ___ Informational purposes at professional meetings, educational seminars or general public.

___   ___ Publishing for educational use in such items as newsletters, website, etc.

________________________________               ______________________

Signature of the Client or Standardized Patient                      Date

________________________________               ______________________

Witness Signature                                                              Date