Your browser is unsupported

We recommend using the latest version of IE11, Edge, Chrome, Firefox or Safari.

Formulario de Consentimiento de Medios de UIC para Individuos

I, the undersigned, do hereby consent to the use by the University of Illinois Chicago (University) of my name, quotes, image, or likeness, and voice for any purpose on behalf of the University. This may include, but is not limited to, use in print, digital and broadcast marketing materials, posting on websites and social media platforms, educational presentations, and for sharing with external news media.

I understand that the University will be unable to prevent others from gaining access to online materials and will be unable to prevent others from copying, altering or republishing my image or likeness.

I understand and agree that I will not be compensated for these images and that the University will forever own the images and their copyrights, and I waive any right to inspect or approve the finished photograph, video or audio recording.

I understand that this consent is perpetual, that I may not revoke it, and that it is binding on me, my heirs and assigns.

I warrant that I am at least 18 years of age and that I am competent in my own name insofar as this consent is concerned. I further attest that I have read this consent form and fully understand its contents.

Nombre del sujeto (Requerido)(Required)
Persona que será fotografiada, grabada o citada.
Correo electrónico (Requerido)(Required)
El profesorado, personal y estudiantes deben usar su dirección de correo de UIC.
Fecha de nacimiento (Requerido)(Required)
Dirección
MM slash DD slash YYYY
Nombre del padre, madre o tutor (si el sujeto es menor de 18 años)
Clear Signature
Contacto del personal de UIC/UI Health (Requerido)(Required)
Correo electrónico del personal de UIC/UI Health
Una copia de este formulario será enviada a esta dirección.
This field is for validation purposes and should be left unchanged.