Release and Non-Disclosure Agreement

As a simulation participant taking part in training opportunities offered virtually or in person at Carolinas Simulation Center (“CSC”), a medical simulation center owned and operated by The Charlotte-Mecklenburg Hospital Authority d/b/a Atrium Health (“CMHA”), I hereby voluntarily and knowingly agree to give my express consent to the following:

1. I grant CMHA a perpetual, world-wide, royalty free license and permission to record, use, disclose, portray, reproduce, broadcast, stream, post, print and publish my likeness, picture and video, whether in digital, electronic, print, video, oral or televised form (the “Information”), for CMHA’s current or future internal and external educational and research purposes on behalf of CMHA (including on behalf of CSC as well as its hospitals, practices, programs and associated foundations). I understand that such information will be the exclusive property of CMHA, free and clear of any claim on my part and may be used in future video or print projects, in whole or in part. I also authorize CMHA to collect performance data related to my participation in the training programs at CSC.
2. I specifically authorize such Information to be published and reproduced in professional journals and medical books; to be used for any other purpose which CMHA may deem fit in the interest of medical education or research; and to be used at professional meetings of any kind.
3. I authorize the editing of the Information, and the publication of information relating to my case(s), either separately or in connection with the publication of the Information, so long as the modifications do not substantially change the nature of the case.
4. I understand that I will not be compensated for the permissions, licenses, or use of the Information. I also understand that CMHA is only responsible for its own actions, and does not control third parties, including other media outlets. I agree to release CMHA, their commissioners, directors, officers, and employees from and against any liability related to their use of the Information.

I also agree to the following:

1. Although I have given permission to the publication of all details and photographs concerning my case(s), it is understood that I will not be identified by name.
2. I understand that all information regarding the case(s) for which I have been trained is the confidential property of CMHA and I agree that I will not disclose to any third party any information about the case(s) or information about the students whom I have seen during any project.
3. I will not video record or take still pictures during live streaming of scenarios.
4. While it is not anticipated that any actual patient-level data will be made available to me, I understand I must treat all patient data communicated to me as Protected Health Information (PHI); that I will abide by all rules and regulations governing that data, including but not limited to Health Insurance Portability and Accountability Act (HIPAA); and I will not disclose PHI in any way that might violate HIPAA or state laws governing patient privacy.