Video Consent Course Title * Please list the course title. Faculty Name and Professional Title: * Please list your name and title as they should appear on the website and other promotional materials. Mobile Number: * Please enter your contact information so that we can reach you while you're traveling. F. Baptist Health CME Portal Learning Management System Consent to VideoI, the undersigned, do hereby voluntarily participate and give authorization for myself to appear in filming, photographs, videotaping, audiotaping and/or interviews for medical, clinical, and hospital education and training. I do hereby consent to the specific use of such production, which includes my name, likeness, and the content I present, for continuing medical education.I do hereby release Baptist Health South Florida, its agents, and its employees from all liability in connection with the above-referenced educational content. I waive any right to inspect or approve the finished product or the advertising or other copy that may be used in connection with the educational content produced. I hereby consent to the use of such content for continuing medical education, without expectation of remuneration to me now or in the future, and this shall be binding upon my heirs, personal representatives and assigns.Specific Use: The video and/or audio recording will be used strictly for non-profit educational purposes of the Baptist Health South Florida Continuing Medical Education Department described above. It will not be sold to a third party, individually or in combination with other presentations, as an educational tool now or anytime in the future. Please Initial * Attestation I attest that the information provided above is true and correct and that I have read and agree to all the terms of this Invitation as stated and described herein. * Please sign your name. Email * Date * Month MonthNov Day Day11 Year Year2024 Need to contact us?Baptist Health CMEBaptist Health Education CenterBaptist Hospital8900 North Kendall DriveMiami, FL 33176Phone: 786-596-2398Fax: 786-533-9821Email: CME12@BaptistHealth.net Leave this field blank