601.483.0011
Click the “Choose File” button below and select the baby photo that you would like to have featured in our SnuggleBunnies campaign. Please upload a high-quality JPEG image that is no larger than 7 MB.
Complete the online information and authorization/release form below. Forms must be completed by the child’s mother – no one else is authorized to send photos for inclusion.
(A) INFORMATION TO BE USED AND DISCLOSED: For and in consideration for the use, disclosure, and publication of the photograph I am submitting for the OCHSNER RUSH MEDICAL CENTER SnuggleBunnies campaign and for other valuable consideration, I, (NAME OF MOTHER), hereby authorize the use or disclosure the photograph of (NAME OF CHILD; hereinafter “Child”) and the information described herein for OCHSNER RUSH MEDICAL CENTER to use, publish, and disclose for the purpose of and in connection with the SnuggleBunnies campaign. The campaign includes billboard and online publication of the photograph and information I am submitting on Facebook and on the Ochsner Rush Health website. I also hereby authorize OCHSNER RUSH MEDICAL CENTER to identify the physician/provider who delivered Child as (NAME OF PHYSICIAN/PROVIDER).
(B) OPT OUT OR REVOCATION OF CONSENT: If I choose to opt out of the SnuggleBunnies campaign once the photograph has been published, I understand that I must notify OCHSNER RUSH MEDICAL CENTER in writing at Ochsner Rush Health Marketing Department, 1314 19 Avenue, Meridian, Mississippi 39301.
(C) IF PARENT OR GUARDIAN IS A MINOR: If the parent or guardian of the Child is a minor, I, the undersigned, covenant and warrant that I am the parent or legal guardian of the minor parent. I hereby agree to and approve the terms of the Authorization and guarantee performance thereof by me and my child or ward.
(D) PERMISSION FROM PROFESSIONAL PHOTOGRAPHER: I certify that I have permission from the photographer(s) I identify herein to submit the enclosed photograph to appear as part of and in connection with the SnuggleBunnies program. I realize that the photograph may also appear online as well as by mobile phone application, and I have obtained the appropriate permission and consent from the photographer(s) for the use, disclosure, and publication of the photograph, including, specifically, for the OCHSNER RUSH MEDICAL CENTER SnuggleBunnies campaign, written documentation of which I am providing herewith. I understand that if this information is not correct, I may be liable to OCHSNER RUSH MEDICAL CENTER and its affiliated entities, as set forth in Section (F) and that the photograph of the Child will no longer appear as part of the OCHSNER RUSH MEDICAL CENTER SnuggleBunnies campaign.
* Must identify photographer and contact information if photograph was professionally taken.
By initialing the following line, I am confirming that the photograph was taken by me personally and was not professionally taken and that I hereby license and consent to the use, publication, and disclosure of the photograph in connection with the SnuggleBunnies campaign, unless and until I revoke my consent and authorization pursuant to the terms and provisions of Section 1(B). (Initials)
(E) RELEASE FROM LIABILITY: I hereby release OCHSNER RUSH MEDICAL CENTER, and Ochsner Rush Health, Inc., and their affiliates, members, directors, officers, physicians, nurses, employees, agents, successors, and assigns and anyone for whom OCHSNER RUSH MEDICAL CENTER may be liable (“Released Parties”) from any and all claims or demands of every kind that I have, or in the case of a parent/guardian of a minor parent/guardian, may now or hereafter have against Released Parties in connection with the appearance of Child in connection with the OCHSNER RUSH MEDICAL CENTER SnuggleBunnies campaign.
(F) INDEMNITY. The undersigned hereby agrees he/she shall indemnify and hold Ochsner Rush Health, Inc., Ochsner Rush Medical Center, and their affiliates, members, directors, officers, physicians, nurses, employees, agents, successors, and assigns (collectively “Ochsner Rush Health”) harmless from and against all liabilities, costs, damages, and expenses (including, without limitation, attorneys’ fees and associated costs) resulting from or attributable to the acts or omissions of Rush arising from, in connection with, or related to the SnuggleBunnies campaign or the use, disclosure or publication of the photograph provided. This indemnity agreement shall survive the period of time during which the photograph or information is used, disclosed, or published.
To the extent I have authorized the individually identifiable health information as set forth in Section 1 above related to Child by OCHSNER RUSH MEDICAL CENTER for the use and disclosure on Facebook, websites, and billboards as part of the SnuggleBunnies program, I understand that this authorization is voluntary; and I understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information may be re-disclosed and may no longer be protected by federal privacy regulations. The specific description of the information that I have directed shall be disclosed is the DATE OF BIRTH of the Child, the FACILITY in which he/she was born, and the PROVIDER. The purpose of the use or disclosure is at my request. I understand that this authorization will expire thirty-six (36) months from the date this Authorization is signed. I understand that I may revoke this authorization at any time by notifying OCHSNER RUSH MEDICAL CENTER in writing; but if I do, it will not have an effect on any actions taken before OCHSNER RUSH MEDICAL CENTER received the revocation. The revocation must include the Child’s name and date of birth and be sent to the address identified in Section 1(B). I understand that I may refuse to sign this authorization and that OCHSNER RUSH MEDICAL CENTER will not condition treatment or payment related to healthcare services on whether I sign this authorization. OCHSNER RUSH MEDICAL CENTER will not receive direct or indirect remuneration or compensation in exchange for using or disclosing the information described and /or listed above.
