Photo Authorisation Form

Photo Authorisation Form
I am completing this form as

Students & visitors are filmed & photographed in connection with Ippon Karate Academy for the following purposes:

- Administration (ID badges etc)

- Coaching and training aids

- Advertising, publicity, and promotional works

- Recording a of events including student’s progress, a celebration of success and achievement

- Dojo Security Evidence

In order to promote the activities of Ippon Karate Academy and/or to produce training material, Ippon Karate Academy staff may from time to time take photos or produce videos of students and families (or authorise a third party to do so) who are participating in events (‘Events’ mean any presentation, excursion, function, meeting, training session or competition of any nature in relation to karate) for use on digital media including the organisation website, Facebook, You Tube, organisation newsletters, community newsletters or newspapers, posters & other marketing materials or publications. In addition, results from local, national, or international tournaments and results of grading tests may also be published.

All photographs, images and video made by Ippon Karate Academy shall be the sole and exclusive property of the association and free from all claims by the undersigned, the participant, or any other party. Although Ippon Karate Academy retains the ownership rights to these images, the undersigned will be allowed access to view them and/or obtain copies.

I understand that Ippon Karate Academy:

- will not pay or compensate me for giving this consent or for the use of any images that include myself or the child I am legal guardian

- may keep the image/s on record until I revoke my consent

- will not publish images if I withdraw this consent, with the exception of those already published

- may use the image in the future, unless I specify limitations for its use
Please initial below that you have read and understood the above statement*

Please indicate in the appropriate check box your authorisation for Ippon Karate Academy to use you &/or your child’s images for the purpose mentioned.
Use of Images
I grant permission to make and retain images including photographic prints, video, film, slideshows and digital imaging of me, my child, or an individual for whom I have authorised decision making responsibility for use as stipulated above by Ippon Karate Academy.*

YES, I authoriseYES, I authorise with limitationsNO, I do not authorise
Limitations of use, please specify below.

Please indicate in the appropriate check box your authorisation for Ippon Karate Academy to use you &/or your child’s images for the purpose mentioned.
Use of Names
I grant permission to publish names of me, my child or an individual for whom I have authorised decision making responsibility for use as stipulated above by Ippon Karate Academy.*

YES, I authoriseYES, I authorise with limitationsNO, I do not authorise
Limitations of use, please specify below.

Please indicate in the appropriate check box your authorisation for Ippon Karate Academy to use you &/or your child’s images for the purpose mentioned.
Publishing of Results
I grant permission to publish grading or tournament results of me, my child or an individual for whom I have authorised decision making responsibility for use as stipulated above by Ippon Karate Academy.*

YES, I authoriseYES, I authorise with limitationsNO, I do not authorise
Limitations of use, please specify below.

Parent/Guardian Full Name*

First NameLast Name
First Student Full name (if under 18 years)*

First NameLast Name
Second Student Full name (if under 18 years)

First NameLast Name
Third Student Full name (if under 18 years)

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
Student Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Photo Authorisation Form

Use of Images

Use of Names

Publishing of Results