New Hanover Wilmington NICU Photo Request

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Please only fill out one form if you have multiple babies.

Please leave blank for office use only.

Current Bed Number or Room Number of your baby *

Baby's name (per hospital records) *

Guardian First and Last Name *

If you are not present for your baby's photo session(s), do we have permission to photograph your baby without a family member present? *

Yes, please take photos of my baby without me there

No, please only take photos if a family member is present

Frequency of photo sessions *

Repeat Session: Sign up my baby for once a month sessions during their NICU stay

One Time Session: My baby will probably not be in the NICU longterm and will only need one photo session

Holidays: If my baby is in the NICU during a holiday event, please take photos for me!

Required

What is your relationship to the baby/babies *

Mother

Father

Temporary Guardian

Foster Parent

Adoptive Parent

Other:

If you have multiples, please let us know how many below

What is your baby's current weight

Baby's Gender *

Preferred email for photo delivery *

Permission Information

Please read and then initial below.

1. The photographer is your guest

The professional photographer that is assigned to your NICU session will enter the NICU as a guest of your family. We ask that your baby's nurse be informed that a photographer will be visiting to photograph your baby on the day of your photo session.

2. Protection of your privacy

The name of your baby and your family is protected and will not be shared publicly by Capturing Hopes at any time. Our photographers have signed an agreement that includes protection of your privacy as well.

3. Social Media

We like to share sneak peeks of each of our NICU photo sessions on our social media platforms to raise more awareness of this free program and support service for families. Our social media platforms are Facebook (Capturing Hopes), Instagram (Capturing Hopes Photo), and TikTok (@TheNICUPhotographer). *Optional below

4. Permission to Photograph

By filling out this form, you are giving permission for the Capturing Hopes affiliate photographer to capture images of your baby and any family present that chooses to be in a photo with the baby. At no time will the photographer or Capturing Hopes ask for payment for services or digital images for your baby's NICU sessions.

5. Ownership of photography

The photos that are captured by Capturing Hopes or the affiliate photographer remain the sole copyright of that photographer. If at any time a hospital, media, online newsite, magazine, or any other company or organization would like to publish those photos, written permission must be obtained from the photographer and Capturing Hopes, and both must receive proper photo credit within that publication.

Initial below consenting to the above permission information *

If your baby's photos cannot be posted on our social media or website, please let us know below.

Would you like information on a newborn photo session when you are discharged? *

Yes, please send me information on newborn and/or family photos

No, I already have a photographer booked

I am not interested in photography following the NICU stay

If your baby has any special health conditions that the photographer should know, please let us know below

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