Fillable Printable Photography Consent Form Template

Photography Consent Form Template

CONSENT FORM

I hereby grant the National Institutes of Health, Office of Research Services, Division of

Occupational Health and Safety (DOHS) of the United States Department of Health and Human

Services, and its designees or assignees, my consent to use, in whole or in part, my photographic

image, as incorporated in the photograph/s submitted by:

____________________________________________________________________________________

(Print Name Clearly)

to the “In Focus! Safe Workplaces for All” photo contest, for the purpose of reproducing,

distributing, displaying publicly, and/or modifying the photo by any means, whether in print or

electronically, on a royalty-free, worldwide basis.

In regard to the use of these photographic images, I hereby waive any right that I may have to

monetary compensation, or to inspect or approve the finished product, or the advertising or other

uses made of the product. I also release the DOHS and its designees or assignees from any and

all liability that may or could arise from the taking and use of these photographic images.

I have read and understand the assignment and release conditions described above. All of my

questions concerning this form have been answered to my satisfaction. Submit questions to

ORSSafetyDay@mail.nih.gov, or send written questions to:

NIH, OD, ORS, DOHS

Attn: DOHS Photo Contest Questions

Bldg 13, Room 3K04

13 South Drive, MSC 5760

Bethesda, MD 20892-5760

Signature: ____________________________________ Date: __________________________

(Parent or Guardian Must Sign for a Minor)

Name: _______________________________________________________________________

Address: ______________________________________________________________________

E-Mail: __________________________________ Phone: ______________________________