I, __________________ (“Participant”), willingly provide my consent to participate as a simulated patient in a health assessment video demonstration conducted by __________________ (“Student”), a nursing student enrolled at Capella University.

For consideration acknowledged, I permanently and irrevocably agree to the following terms and conditions:

Purpose

I acknowledge that the video content (“Content”) created will solely be used for educational purposes. These purposes include but are not limited to:

Demonstrating clinical health assessment skills for academic evaluation.
Completing a comprehensive assessment that includes a subjective, objective, assessment, and plan (SOAP) note as outlined in the course curriculum.
Providing hypothetical health information for use in simulated clinical assignments.

I also understand that I waive the right to review or approve the Content prior to its educational use by Capella University.

Content

I grant consent to be recorded for the creation of the Content, which includes both the video demonstration and the collection of information needed to prepare the SOAP note.

For the purposes of this Waiver, “Content” is defined as: recorded video material created for educational purposes, my image, appearance, voice, and likeness as captured in the video, and any information collected by the Student to complete the SOAP note.

Disclosures

I understand that all materials produced are for demonstration purposes only and do not represent medical advice, clinical judgment, or actual diagnosis. Neither the Student nor I am obligated to disclose real medical history or personal health information.

Any personal data used (beyond age and gender) may be hypothetical. However, certain health readings such as vital signs may reflect my actual physiological information.

Voluntary Consent and Use

I voluntarily grant Capella University the unrestricted, royalty-free right to use, reproduce, distribute, display, and publish the Content strictly for educational and assessment purposes. The Content may be shared with the course instructor, faculty, or authorized staff but will not be used for purposes beyond academic evaluation.

I waive the right to inspect or approve the Content before its use and to pursue damages, compensation, or claims related to the use of the Content, including image distortion, alterations, or reproduction errors.

Rights and Ownership

I acknowledge that Capella University shall retain complete ownership of the Content. This includes exclusive intellectual property rights, meaning the Content will be considered the sole property of Capella University.

I release Capella University from any claims linked to the creation, distribution, or use of the Content and from any potential injuries, damages, losses, or expenses I may incur as a result of participating in the simulation.

Waiver and Release

I waive and discharge Capella University, including its affiliates, employees, students, trustees, contractors, and representatives, from all liabilities or claims that may arise from the production, sharing, or educational use of the Content. This waiver extends to all forms of injury, damages, expenses, or legal actions resulting from my participation.

Governing Law and Venue

This Waiver shall be governed by the laws of the State of Minnesota. Any disputes arising from this agreement will be handled in Minnesota state or federal courts.

Participant Acknowledgment

By signing below, I confirm that I am at least 18 years of age, have read this Waiver thoroughly, and fully understand its terms. I voluntarily accept the conditions stated above without any coercion or undue influence.

Signatures

Role	Printed Name	Signature	Date
Student	_________________________	__________________________	__________
Participant	_________________________	__________________________	__________

References

Capella University. (2023). Capella University nursing program handbook. Minneapolis, MN: Capella University.

American Nurses Association. (2021). Code of ethics for nurses with interpretive statements. American Nurses Association.