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Please click all that apply. (Example: If you were at Eagle Ridge Hospital and also the Royal Columbian Hospital, select Port Moody and New Westminster.)
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Your image, voice, comment, testimonial and/or other information (the “Materials”) was recently recorded
by or for Fraser Health Authority (“Fraser Health”). You have been asked to review this form in
order to provide your consent for Fraser Health to use the Materials. You understand and that your
consent is voluntary and you are under no obligation to sign this consent form.
By providing consent you irrevocably consent to the use of the Materials throughout the world
by Fraser Health in its sole discretion and without compensation to you. “Use” in this consent form
means: i) unlimited disclosure of the Materials for internal or external non-commercial use in all forms,
media and technologies now known or hereafter developed, including via the Internet; and ii) the right to
change or modify the Materials, and to use the Materials alone or to combine them with any other
materials. You agree that Fraser Health owns all rights to the Materials and that it may, but is not
obligated to disclose your name in connection with its use of the Materials.
You represent and warrant that you waive any rights you may have with respect to the Materials,
including any moral rights or any right to inspect or approve the Materials or the context in which Fraser
Health uses them.
You acknowledge and agree that you are giving up your rights to sue and that you have no right to
approve the use of your image, voice, comment, testimonial or other personal information in the
Materials. You agree that Fraser Health and its representatives will not be liable to you for their use of the
You represent and warrant that you have read and understood this consent form, that you are at least 19
years of age and that you are entitled to enter into this consent form. In the event that any of the Materials
include the image, voice or other personal information of a minor under 19 years of age, you represent
and warrant that you are the parent or legal guardian of that minor and that you have the authority to, and
do, consent and agree on behalf of them. In that case, any references in this consent form to “you” or
“your” will be read as references to you on behalf of the minor.
Your personal information is being collected under Section 26 of the Freedom of Information and
Protection of Privacy Act for the purposes described in the consent form above. If you have any questions
regarding the collection of your personal information under this consent form, please contact Seana-Lee
Hamilton, Manager, Information Privacy, Fraser Health Authority, Suite 100, 13450 – 102nd Avenue,
Surrey, B.C. V3T 5X3, Tel: 604-953-5015.