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Prior to publishing, exhibiting, or otherwise using any image from the Pennsylvania Hospital Historic Image Collection, you will be asked to read, complete, sign and submit the following form for approval by the Pennsylvania Hospital Archivist.

Permission to Publish and/or Exhibit Materials
From the Pennsylvania Hospital Historic Collections

800 Spruce Street, Philadelphia, Pennsylvania 19107

Name: _______________________________________________________________________

Institution: ____________________________________________________________________

Address: _____________________________________________________________________

Phone: ________________________________ Email: _________________________________


I, the undersigned, as a representative of __________________________________, wish to
publish and/ or exhibit the following materials from the Pennsylvania Hospital Historic Collections:
(Please be as specific as possible)

I/ we will be using the aforementioned materials in the following publication/ exhibit:
(please provide title of work and publication date, if known. If using items in an exhibit, please include dates of use.)


Please carefully read the following policy and regulations concerning use:

1) In providing permission to publish material obtained from the Pennsylvania Hospital Historic Collections, the Hospital does not assume any responsibility for infringement of copyright or of publication rights for materials that might be held by others. The publisher/ undersigned assumes all responsibility for any claims under the Copyright Law or the laws of libel that could be made as the result of the publication.

2) The responsibility for obtaining any additional permission required for publication of archival materials remains with the publisher of the material.

3) The publisher/ undersigned understands that he/ she will be granted one-time, non-exclusive rights to use Hospital materials. The Pennsylvania Hospital retains the right to publish, and provide to other patrons, said materials. Any subsequent use of said materials by the publisher/ undersigned will require additional permission, and is subject to additional publication/ use fees. Images may not be transferred to another individual or organization, be deposited at another institution, or be reduplicated without prior permission of the Pennsylvania Hospital.

4) The publisher/ undersigned agrees to cite the source of archival material in all published works and exhibits. A dissertation is considered a published work. All materials should be credited as follows: "Courtesy Pennsylvania Hospital Historic Collections, Philadelphia."

I have read the policy as stated above and agree to comply with its regulations.

Signature: _________________________________________ Date: ______________________

Approved By: _______________________________________ Date: ______________________


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