Adventist University of the Philippines

COLLEGE OF NURSING

Photo and Video Consent

(Pahintulot sa Pagkuha ng Lawaran at bidyo)

I am willing to participate in the case study by granting permission to use my photo or

video for educational purpose only. By signing this document, I agree to the following:
1. Recording of picture and voice of myself and family (i.e., photos, audio, or video)
2. Sharing my photos or opening it via print or electronic type, which may include the
internet.
3. No payment will be made for the right to obtain or use your photo or video or
audio recordings.

Nature of image and/or spoken words to be recorded (Ang uri ng larawan at/o mga
salitang itatala):
Appropriate images, records and videos must only be included.

Purpose of recording, image and/or spoken words, including the intended audience (Layunin
ng pagtatala, larawan at /o mga salitang gagamitin kasama ang mga taong manonood):
For health purposes only and the person who is intended to do this will only be the one who will have the
information.

Restrictions and Limitations (Mga Bawal Gawin at Limitasyon):

None
Specify, if applicable:

I have read and fully understood the intent and purpose of this document and signed it without
reservation/Nabasa ko at lubos na nauunawaan ang intensyon at layunin ng dokumentong ito at pinirmahan
ko ito nang walang reserbasyon:

Name/Pangalan: Lloyd Lagan Signature/Pirma:

Date/Petsa: June 15, 2021 Witness/Saksi: Valdemor Lagan

Name and Signature /Pangalan at pirma