I understand St. Francis Healthcare System intends to use the name and any photos of my loved one that I submit in a respectful manner for the Light Up a Memory video. This event video is designed to honor loved ones of families and to be viewed by the public, and will be posted on the St. Francis Healthcare System website and used for possible future marketing purposes. St. Francis Healthcare System will not be responsible for how this event video may be used by the general public. I may provide written notice to St. Francis Healthcare System to revoke this authorization at any time. Upon notification, St. Francis Healthcare System will remove the name and photos of my loved one from the event video. I further understand this authorization is not connected in any way to admission, treatment, or payment for any services provided by St. Francis Healthcare System.
I am an authorized representative of my loved one and agree to the terms above.