Media Consent Form

Name of Person Completing Form *

First Name

Last Name

Name of Child (if applicable)

First Name

Last Name

The organisation named above can take photograph/video clips for the purposes of intervention planning *

Yes

No

The photograph/film may also be viewed by the committee *

Yes

No

I understand that I may withdraw any or all of these consents at any time and will contact the organisation if I wish to do so *

Yes

No

I give my consent for the photograph/film to be used in future training or social media/websites - this will be used no longer than 50 years *

Yes

No

I give my consent for the photograph/s to be used in publications/web based materials to showcase community activities we deliver and advertise new events for no longer than 50 years *

Yes

No

I understand that I may withdraw any or all of these consents at any time any will contact the organisation if I wish to do so *

Yes

No

I am happy for you to contact me to tell me about future community events and activities *

Yes

No

Name *

First Name

Last Name

Parent/Care Name (if applicable)

First Name

Last Name

Date *

MM

DD

YYYY