Participation & Art/Image Release
In the interest of promoting the Expressions of Hope & Healing program and its ongoing mission, this form indicates my consent for the Outer Banks Hospital and Dare County Arts Council to use images of my artworks and/or myself.

These images will be for the purpose of informing the public concerning program activities, or for artistic, educational, marketing, or any other purpose as deemed necessary by either the Outer Banks Hospital or the Dare County Arts Council.
Name *
Your answer
Email *
Your answer
Photos, Videos & Audio of me/my art may be used by the Expressions program, Dare County Arts Council or the Outer Banks Hospital. I will not be identified by name, unless I also consent to that, below. *
I understand that the photographs, video, or audio recordings shall be used for publicity, education, or science; such photographs/recordings and information relating to my participation may be published and republished, exhibited either separately or in connection with each other, on social media, in professional journals, used in the institutions’ internal or external websites, or used for any other purpose deemed proper in the interest of medical education, artistic education, knowledge, research, or to promote activities at the Outer Banks Hospital or the Dare County Arts Council. However, it is specifically understood that in any such publication or use, I shall not be identified by name without my consent as indicated below (see item #4). I grant this consent as a voluntary contribution in the interest of medical and artistic education and knowledge, or to promote the related activities of the hospital or arts council.
I will not be paid if Photos, Videos or Audio of me/my art is used by the Expressions program, DCAC or the Outer Banks Hospital. *
I waive all rights I may have to any claims for payment or royalties in connection with any exhibition, televising, or other showing of these films, electronic images, or photographs, regardless or whether such exhibition, televising or other showing is under philanthropic, commercial, institutional, or private sponsorship.
These images & videos may be retouched. *
I understand that photographs, electronic images, or films may be edited, modified, or retouched for artistic purposes, to withhold identity, or for any other graphic production reason.
I may be identified by name in these: *
Select all that apply:
Sign Here
Type Your Name as your eSignature *
By providing my signature, I affirm that I understand and agree to each of the above terms and conditions. I understand that typing my name below will constitute my electronic signature, and is a valid and legally binding signature.
Your answer
The current date and time will be automatically included with your form submission
Never submit passwords through Google Forms.
This form was created inside of Bold Print Design Studio, Inc.. Report Abuse