Photography Request Form Photography request form Please complete the form below, required fields = * Start time and date requested for photo session* : AM PM AM/PM End time* : AM PM AM/PM Date of Session* MM slash DD slash YYYY Location of assignment*Please provide address and directions to locationStaff Member requesting* Email* Enter Email Confirm Email Phone*Format (###)###-###On date of request: To be present (yes/no)?* yes no Photo subject(s)*Name (please note, if more than one subject, please name them in the description filed): Title:*Title: College and department:*College and department: Contact number:*Contact number: Email* Project Name/Story slug*One to two words Project Details*Description of your photography project including intended audiences and types of medium images will be reproduced in. If you have a desired “look” or an idea for your photography project please include links to sample images with photo request.Project Keywords*Please enter relevant keywords separated by commas.PHI Consent Information*Enter PHI consent information: Treating physician, service line/campaign name/news story, staff member obtaining consent, etc...What is the Purpose of Sharing the PHI? Check all that apply*Check all boxes for the appropriate uses of these photos, and then remember to check off all boxes when having the PHI form signed by the patient. (As many as possible so that photos can be used for multiple purposes.) Select All Marketing News Media Public Relations Publication (e.g., brochure, online journal, book) Fundraising Not Applicable Name of Intended publication(s)*Please list the publication(s) this photo is intended forThese photos are ONLY for my specific campaign/project and not available to others for future use.* Yes No Designer Assigned*Please indicated designer working on this project.NoneSelena CarterMary CeceliaMadelyn HyderMichael McAleerPublication deadline* MM slash DD slash YYYY Cutline for photo Story summarySlide show/Multimedia requested* yes no
