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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

Media, Audio/Visual, Presentation, and FERPA Release Statement

Click to download consent fillable consent form

Digital agreement:
I agree to grant The University of North Carolina at Chapel Hill (“University” or UNC) and Maternal Health Learning and Innovation Center (MHLIC) partners the right and permission to use and distribute video, 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, online properties/website, presentations, promotional literature, social media, digital, or local advertising, or for any other purpose related to the mission of MHLIC. I understand that I may 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 of the materials can be used by MHLIC team and remain on the MaternalHealthLearning.org site and/or partner properties. I hereby release and discharge MHLIC team and partners 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 invasion of my privacy, right of publicity, defamation, copyright infringement, or any other causes of action arising out of the use, adaptation, reproduction, distribution, broadcast or exhibition of such media.

Presenter Material and Promotion: Regarding presentation material and recording, I expressly grant permission to record my presentation and/or comments in any and all forms, in the named event. I acknowledge the public promotion of the content, including photos, audio and sound bites, affiliation title and logo, screenshots, and more. My presentation may be crafted into a podcast or blog, YouTube video, included in the MHLIC Resource Center, and used for promotion and educational purposes online.

I grant permission to use, encode, digitize, copy, edit, transcribe, excerpt, transmit, display and publicly share the video, slides, and resources, as well as use my name, voice, likeness, biographic information and any material related to this presentation. Unless agreed upon, I understand I may not have the right to inspect or approve the finished electronic, photograph, or printed matter that may be used in conjunction with them now or in future work. I warrant that I have the right to authorize the licensee to reproduce, distribute, adapt, display and publicly perform the content presented. I release MHLIC from liabilities incurred by the licensee as a result of the licensee’s transmission, and/or distribution of the content, including but not limited to defamation, rights of privacy or publicity, copyright, patent rights, trade secret rights, moral rights, or trademark rights.

FERPA RELEASE: I understand that the media presented 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 confirm that I am competent to contract in my own name. This release is binding upon me and personal representatives.

I understand and agree to the above terms.

I agree

For questions, email KSheppard@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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