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Maternal Health Learning and Innovation Center

Maternal Health Learning and Innovation Center

Accelerating innovative and evidence-informed interventions that improve maternal health and eliminate maternal health inequities

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MHLIC / UNC Consent Form

VIDEO / PHOTOGRAPH CONSENT FORM and FERPA RELEASE

Click to download consent fillable consent form

Digital agreement:
I hereby grant The University of North Carolina at Chapel Hill (“University” or UNC) and Maternal Health Learning and Innovation Center (MHLIC) partners the irrevocable right and permission to use and distribute video and audio footage and/or still photographs (“media”) of me that are taken during my participation in the event and/or activity as described by the MHLIC and UNC team.

The intended use of this media is brochures, publications, Internet website, audiovisual presentations, promotional literature, advertising, or for any other purpose related to the educational mission of the University. I understand that I will not be compensated for the use of the media of me.

I understand and agree that I may be identified by name and title in information that might accompany the media of me. I agree that all such portraits, pictures, photographs, video, and audio recordings and any reproductions thereof, and all plates, negatives, recording tape, and digital files shall remain the property of The University of North Carolina at Chapel Hill. I waive the right to approve the final product.

I hereby release and forever discharge The University of North Carolina at Chapel Hill, its trustees, agents, officers and employees, from any and all claims and demands arising out of or in connection with the use or distribution of said media, including but not limited to, any claims for invasion of privacy, appropriation of likeness, violation of copyright, and/or defamation.

FERPA RELEASE: I understand that the media may be protected by the Family Educational Rights and Privacy Act (“FERPA”) as education records. I hereby authorize the University to release the media from this event to faculty, staff, students, and visitors to of the University, which may include the general public. The purpose of the disclosure is to advance the educational mission of the University.

I hereby warrant that I am eighteen years old or more and competent to contract in my own name. This release is binding upon me and my heirs, assigns, and personal representatives. This consent shall remain in effect until revoked. A copy of this Consent shall have the same force and effect as the original.

I understand and agree to the above terms by emailing “YES” to my UNC/MHLIC contact.


If individual photographed/recorded is under eighteen (18) years old, the following section must be completed: I have read and I understand this document. I understand and agree that it is binding on me, my child (named above), our heirs, assigns and personal representatives. I acknowledge that I am eighteen (18) years old or more and that I am the parent or guardian of the child named above.

I understand and agree to the above terms by emailing “YES” to my UNC/MHLIC contact.

For questions, email Tamala_grissett@unc.edu.


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This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U7CMC33636 State Maternal Health Innovation Support and Implementation Program Cooperative Agreement. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.
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