Photo and Filming Consent Form for Patients & Staff by aiPADj2I

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									APPENDIX A
                                                       Poster Consent Form
                                                    Open Day: 24 September 2011
In respect of the poster competition, Croydon Health Services would like to obtain consent to use the
submitted poster for promotional purposes.

Consent is requested for the design to appear in our printed publications, on video and on our website. Please
note that websites can be seen throughout the world, and not just in the United Kingdom, where UK law
applies




Name:

Address:

Contact tel no:


I agree for the poster to be displayed at Croydon Health Services’ Open Day if the poster is shortlisted.

I agree that the poster design can be used in printed publications produced by Croydon Health Services, in
training or promotional presentations/videos and on the Croydon Health Services’ website.

I understand that the poster design will be a true and faithful representation of Croydon Health Services’ Five
Promises to the People of Croydon and be in no way derogatory or demeaning.



Signed ..................................................................................................................................

Date………………………….………………………………………………………………….........



Signature of parent or guardian of any person under 16 years of age.


Signed ..................................................................................................................................

Date……………………………………………………………………………………………………

Child’s date of birth ………………………………………………………………………………….


The form is valid for five years from the date of signing this form. Your consent will automatically expire after
this time.

We will not include full names of any person in the image without good reason. We will not include personal e-
mail or postal addresses, telephone or fax numbers in any publication.




Please attach this form to the back of the poster

								
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