I hereby authorize The University of Texas Southwestern Medical Center (UT Southwestern) and those acting pursuant to its authority to:

(a) Record my likeness and voice on video, audio, photographic, digital, electronic, or any other medium (the “Media”) taken or made on behalf of all UT Southwestern activities.
(b) Use my name in connection with the Media.
(c) Use, reproduce, exhibit or distribute in any medium (e.g., print publications, e-mail, video, Internet) the Media for any purpose that UT Southwestern and those acting pursuant to its authority deem appropriate, including educational, promotional, or advertising efforts.

If I am a student at UT Southwestern, I understand the Media may constitute educational records under the Family Educational Rights and Privacy Act and by signing this Release, I consent to UT Southwestern’s use and disclosure of the Media.

I acknowledge that I will not receive any compensation for the use of such Media, and I hereby waive any right that I may have to inspect or approve the finished product or products or the use to which they may be applied.

I release UT Southwestern and those acting pursuant to its authority from liability for any violation of any personal or proprietary right I may have in connection with such use of the Media. I understand that all Media shall remain the property of UT Southwestern. I have read and fully understand the terms of this release.