Consent to be Recorded Form

Consent to be Recorded Form

ICE's mission is to inspire clinical excellence through the creation of innovative, high-quality, and user-friendly educational resources for faculty, students, and clinicians in health professions.
Full Name*

First NameLast Name
Email*
example@example.edu
Phone Number*

Area CodePhone Number
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Name Permission*

Full nameFirst name onlyDo not use real name
- Name of Representative
  
  First NameLast Name
- Email
  example@example.edu
- Phone Number
  
  Area CodePhone Number
- Relationship of Representative
  
  SpouseParentLegal GuardianOther
- Address