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Full Name of Patient (Mother):_____________________________________________________________

Parents’ first names as you want them to appear on the web. (For example, Tom and Jane Doe would be Tom & Jane). ________________________________________

Request to Participate In and Consent for Taking of Digital Photographs

I the patient, _______________________________________________________ request that one photograph of my new baby/family be included in the hospital internet web nursery site, www.penbayhealthcare.org, for a period of not more than 90 days. I understand that these images and all corresponding data and information can be viewed by anyone with internet access.

I hereby authorize and approve the taking of photographs of my new baby and/or family for the hospital or its authorized agent(s), to display on the internet for viewing subject to the below listed conditions:

That babies will be listed for a period of not more than 90 days.
That first name, middle name, and last initial will identify the baby. Parents will be identified by first names only.
That patient understands photographs, images, information and other data, by being posted on the internet, becomes public information and can be viewed by anyone with internet access.
That all photographs and images shall be the sole property of Penobscot Bay Medical Center or its authorized agent(s) and may not be reproduced without the written consent of Penobscot bay Medical Center.
This consent is expressly intended to release from all liability of any nature Penobscot bay Medical Center, the attending physicians, nurses, consultants of any nature, and all agents and other personnel employed at this the participating hospital with regard to the taking, publishing or viewing of the photographs requested above.

Signed by mother or father: ___________________________________Date: ___________________________

Hospital witness: ____________________________________Date: ___________________________

Baby’s full name: ________________________________________
(If not yet named, please use boy/girl)

Birth Date____/____/_______time______________ am/pm

sex M / F weight_______ lbs.______ oz ________Kg. length ___________ in __________cm.

Siblings first names:_____________________________________________

Staff person handling photo and web information_________________________Date/Time___________

Updated: 6/17/06