{"id":2709,"date":"2020-03-03T19:02:49","date_gmt":"2020-03-03T19:02:49","guid":{"rendered":"https:\/\/littlemedsch.wpengine.com\/midsouth\/?page_id=2709"},"modified":"2024-08-16T20:50:49","modified_gmt":"2024-08-16T20:50:49","slug":"authorization","status":"publish","type":"page","link":"https:\/\/littlemedicalschool.com\/midsouth\/authorization\/","title":{"rendered":"Waiver, Release, &amp; Consent Form"},"content":{"rendered":"\n\n\t<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_21' >\n                        <div class='gform_heading'>\n                            <p class='gform_description'>This form is required for any student participating and\/or volunteering in Little Medical School activities, events, and programs.  You will not be permitted to participate in Little Medical School events without this form electronically signed by a parent or legal guardian.  (You may request a hard copy to sign and return.)  <\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_21'  action='\/midsouth\/wp-json\/wp\/v2\/pages\/2709' data-formid='21' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_21' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_21_52\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_52'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_52' id='input_21_52' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_21_52_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_21_52_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_21_52' class='gform_hidden' value='https:\/\/littlemedicalschool.com\/midsouth\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_21_2\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_2'>Location of Activity, Event or Class<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_21_2' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_58\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Participant Information:<\/h2><\/li><li id=\"field_21_56\" class=\"gfield gfield--type-list gfield--input-type-list gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >List information for each child participating at the above event location.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><style type=\"text\/css\">\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons {\n\t\t\t\t\t\t\tvertical-align: middle !important;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img {\n\t\t\t\t\t\t\tbackground-color: transparent !important;\n\t\t\t\t\t\t\tbackground-position: 0 0;\n\t\t\t\t\t\t\tbackground-size: 16px 16px !important;\n\t\t\t\t\t\t\tbackground-repeat: no-repeat;\n\t\t\t\t\t\t\tborder: none !important;\n\t\t\t\t\t\t\twidth: 16px !important;\n\t\t\t\t\t\t\theight: 16px !important;\n\t\t\t\t\t\t\topacity: 0.5;\n\t\t\t\t\t\t\ttransition: opacity .5s ease-out;\n\t\t\t\t\t\t    -moz-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -webkit-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -o-transition: opacity .5s ease-out;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons a:hover img {\n\t\t\t\t\t\t\topacity: 1.0;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\t<\/style><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_56_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_56_col_2' class='gfield_list_col_even' \/><col id='gfield_list_56_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_56_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th scope=\"col\">Child&#039;s Name<\/th><th scope=\"col\">Date of Birth (MM\/DD\/YYYY)<\/th><th scope=\"col\">Age<\/th><td>&nbsp;<\/td><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_56_cell1' data-label='Child&#039;s Name'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_21_56\" aria-label='Child&#039;s Name, Row 1' data-aria-label-template='Child&#039;s Name, Row {0}' type='text' name='input_56[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_56_cell2' data-label='Date of Birth (MM\/DD\/YYYY)'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_21_56\" aria-label='Date of Birth (MM\/DD\/YYYY), Row 1' data-aria-label-template='Date of Birth (MM\/DD\/YYYY), Row {0}' type='text' name='input_56[]' value=''   \/><\/td><td class='gfield_list_cell gfield_list_56_cell3' data-label='Age'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_21_56\" aria-label='Age, Row 1' data-aria-label-template='Age, Row {0}' type='text' name='input_56[]' value=''   \/><\/td><td class='gfield_list_icons'>   <a href='javascript:void(0);' class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 6)' onkeypress='gformAddListItem(this, 6)'><img src='https:\/\/littlemedicalschool.com\/midsouth\/wp-content\/plugins\/gravityforms\/images\/list-add.svg' alt='' title='Add a new row' \/><\/a>   <a href='javascript:void(0);' class='delete_list_item' aria-label='Remove this row' onclick='gformDeleteListItem(this, 6)' onkeypress='gformDeleteListItem(this, 6)' style=\"visibility:hidden;\"><img src='https:\/\/littlemedicalschool.com\/midsouth\/wp-content\/plugins\/gravityforms\/images\/list-remove.svg' alt='' title='Remove this row' \/><\/a><\/td><\/tr><\/tbody><\/table><\/div><div class='gfield_description' id='gfield_description_21_56'>Click the plus sign to add an additional child.<\/div><\/li><li id=\"field_21_48\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_48'>If extra assistance is required, please describe below.  (LMS is not authorized to administer any medication or medical care.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_48' id='input_21_48' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_21_59\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Parent \/ Legal Guardian Information<\/h2><\/li><li id=\"field_21_57\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name of Parent \/ Legal Guardian<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_21_57'>\n                            \n                            <span id='input_21_57_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_57.3' id='input_21_57_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_21_57_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_21_57_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_57.6' id='input_21_57_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_21_57_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_21_49\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_21_49' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_21_49_1_container' >\n                                        <label for='input_21_49_1' id='input_21_49_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_49.1' id='input_21_49_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_21_49_3_container' >\n                                    <label for='input_21_49_3' id='input_21_49_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_49.3' id='input_21_49_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_21_49_4_container' >\n                                        <label for='input_21_49_4' id='input_21_49_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <select name='input_49.4' id='input_21_49_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_21_49_5_container' >\n                                    <label for='input_21_49_5' id='input_21_49_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_49.5' id='input_21_49_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_49.6' id='input_21_49_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_21_50\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_50'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_50' id='input_21_50' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_21_51\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_21_51'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_51' id='input_21_51' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_21_63\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">RELEASE &amp; WAIVER OF LIABILITY:<\/h2><\/li><li id=\"field_21_36\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >This agreement releases Little Medical School from all liability relating to injuries that may occur during participation in any of our classes or activities, including but not limited to the use of equipment such as stethoscopes, mortars and pestles, blood pressure cuffs, stuffed toy\/plush or any other educational tools provided. By signing this agreement, I acknowledge the inherent risks involved in these activities and agree to hold Little Medical School entirely free from any liability, including financial responsibility for injuries incurred, regardless of whether injuries are caused by negligence or otherwise.<\/li><li id=\"field_21_39\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">USE OF STETHOSCOPE (where applicable for certain classes)<\/h2><\/li><li id=\"field_21_64\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >I acknowledge the risks involved in using a stethoscope. These include but are not limited to ear infections, blown ear drums, wrapping stethoscope around neck, and yanking of stethoscope causing injury. I swear that I am participating voluntarily, and that all risks have been made clear to me. Additionally, I do not have any conditions that will increase my likelihood of experiencing injuries while engaging in this activity. By signing below I forfeit all rights to bring a lawsuit against Little Medical School for any reason. In return, I will receive a stethoscope. I will also make every effort to obey safety precautions as listed in writing and as explained to me verbally. I will ask for clarification when needed.<\/li><li id=\"field_21_60\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">IDENTIFICATION &amp; ASSUMPTION OF RISK:<\/h2><\/li><li id=\"field_21_29\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >IDENTIFICATION AND ASSUMPTION OF RISK:  Participation in the activity, as well as utilization of LMS facilities, carries with it certain inherent risks and potential hazards that cannot be eliminated regardless of the care taken in LMS, including but not limited to, risk of damage, loss, and theft of personal property, as well as injuries (including death) associated with activities and other injuries that may not be foreseeable.  The specific risks vary from one activity to another, but the risks could include, but not be limited to, 1) minor injuries from physical activity including but not limited to scratches, bruises, and sprains 2) injuries from use of medical tools and equipment including but not limited to ear infections, blown ear drums, wrapping stethoscope around neck, and yanking of stethoscope causing injury 3) thefts and criminal intrusions.  \n\nI have read the previous paragraphs and I know, understand, appreciate these and other risks are inherent in LMS.  I hereby elect to voluntarily participate in LMS, and engage in such activity knowing that there may be hazardous to my child and my property.  I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS, PROPERTY DAMAGE OR PERSONAL INJURY, that may be sustained by my child, or any loss or damage to property owned by me, as a result of my child being engaged in LMS, WHETHER CAUSED BY THE NEGLIGENCE OF RELEASES or otherwise.  \n\nBy signing below, I forfeit all rights to bring a lawsuit against Releases for any reason. I will also make every effort for myself and my child to obey safety precautions as listed in writing and as explained to me and\/or my child verbally. I will ask for clarification when needed.\n<\/li><li id=\"field_21_61\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">CONSENT TO PHOTOGRAPH, INTERVIEW, AND\/OR AUTHORIZE THE RELEASE OF INFORMATION<\/h2><\/li><li id=\"field_21_37\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >I consent and authorize to take photographs, video, or other visual images of me and\/or my child and\/or to record me and\/or my child\u2019s voice, the results of which may be published into the public domain in print, visual, or electronic media including, but not limited to: brochures, direct mail, advertisements, newspapers, newsletters, magazines, television, radio, presentations, web sites, trade show displays, and social media. I understand that the visual images or audio recordings may make me and\/or my child\u2019s identity recognizable. I agree that all reproduction and all copyrights associated with the above-described media shall remain the property of Little Medical School. I understand that the use of the communications efforts may directly or indirectly benefit the program financially. I agree that my child and\/or I are not entitled and release any right to any claim my child and\/or I may have related to use of my and\/or my child\u2019s visual images and\/or audio recordings, including but not limited to, any claim for payment or royalty in connection with distribution or publication of these communications.<\/li><li id=\"field_21_62\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">ACKNOWLEDGEMENT OF UNDERSTANDING:<\/h2><\/li><li id=\"field_21_38\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >I understand that I have the right to revoke this authorization in writing at any time by written request to Little Medical School. But the revocation will not be effective to the extent that Little Medical School already relied on my authorization; for example, the revocation will not apply to publications already in production nor will it apply to publications already distributed to the public. 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