Photo Consent and Media Release (Form-1057)

PHOTO CONSENT AND MEDIA RELEASE (Form-1057)
Participant's Details
Name *

First Name Last Name
Date *

Day Month Year
Date
Australian Quality Care uses photos and videos of residents for promotional and educational purposes including on our website, in our printed material and on our social media pages.

Photos and videos of people are considered personal information if a person can be reasonably identified from them. So, Australian Quality Care needs to get your permission (also called consent) to use photos or videos that you are in before we use them for educational or promotional purposes.
By selecting ONE (1) check box, and signing below, you acknowledge and consent, or otherwise, to the following: *

I DO NOT give consent for Australian Quality Care to use photographs and video of me in educational and promotional materials, programs, activities, and social media platforms. I DO give consent for Australian Quality Care to use photographs and video of me in educational and promotional materials, programs, activities, and social media platforms. By giving my consent, I also understand that:
- Photos or video of me can be used in places including, but not limited to, on Australian Quality Care’s website, in Australian Quality Care’s printed material and on Australian Quality Care’s social media pages.
- Australian Quality Care will make sure photos and videos of me are stored in a safe electronic file.
- All photos and videos remain the property of Australian Quality Care, and, from time to time, Australian Quality Care may need to crop or alter the images to make them suitable for publication.
- Images may be duplicated by Australian Quality Care for use in various educational and promotional materials at multiple times in the future without my prior approval or inspection (unless I have withdrawn my consent prior).
- If I wish to withdraw my consent in the future, I can do so at any time, and I will complete a new copy of this form indicating my withdrawal in writing.
Signature of Participant

*Or signature of person acting on authority under Guardianship Administration Act 2000 or Powers of Attorney Act 1998 for the person named above, OR an Informal Decision Maker (must have an Informal Decision Maker Details Form-1066 signed) for the person named above.
Name *

First Name Last Name
Signature *

Clear
Date *

Day Month Year
Date
In the presence of (Witness)
Name *

First Name Last Name
Signature *

Clear
Date *

Day Month Year
Date
Should be Empty:

PHOTO CONSENT AND MEDIA RELEASE (Form-1057)

Participant's Details

Signature of Participant

In the presence of (Witness)