CCS Disability Action - Communication consent form

Communication consent form

All fields marked with * are required and must be filled.

CCS Disability Action is always looking for opportunities to take its message ‘including all people’ into the wider community. Photographs and personal stories help us to do this in interesting ways that are easily understood. We use these to help inform the community about the lives of disabled people. We will always work hard to show people in a positive, empowering way.

The following sections should be filled in by the person sharing their story and/or image. If the person is under 18 or needs support to give informed consent, they should be supported by their parent/guardian/nominated support person and the form signed by their parent/guardian/nominated support person where applicable.

Please select all that apply.
1. My identity*

I agree for my first name to be used.I agree for my surname to be used.I agree for my location to be used.I agree for my age to be used.I would like to be anonymous. CCS Disability Action should change my first name, surname, location and any particular information that might identify me to protect my privacy and identity.

2. Photographs

I consent to CCS Disability Action using my image in their communications, marketing and fundraising including print, electronic and online.
3. Video footage

I consent to CCS Disability Action using my image in their communications, marketing and fundraising including print, electronic and online.
4. Audio recordings

I consent to CCS Disability Action using my voice in their communications, marketing and fundraising materials.
5. My story

I agree to be contacted by CCS Disability Action’s media team to talk about being interviewed by a newspaper, website, radio or TV journalist.I agree that CCS Disability Action can adapt my words, information and story for communication materials, including marketing and fundraising. I understand that if I tick this box, adapted versions of my words, information and story will be shared with me so they can make sure I am comfortable with what has been written.

6. Permission

I agree for my and/or the child’s (for whom I have parental responsibility) words, information, story, photographs, video and audio – as set out in sections 1 to 6 of this form – to be used by CCS Disability Action and its partner organisations in printed, online or electronic publications, which may be shared publicly. Examples include, but are not limited to: posters, leaflets, brochures, adverts, emails, e-newsletters, fundraising letters, banners, blogs, web pages, social media posts, presentations, speeches, research or policy reports and press releases or other materials. I understand that this permission extends until I notify CCS Disability Action that I would like to withdraw my consent.

7. One off use only

I agree for my and/or the child’s (for whom I have parental responsibility) words, information, story, photographs, video and/or audio to be used by CCS Disability Action and its partner organisations for a one-off use only.
Please specify use

8. Personal details

The details below are for office use only and will not be shared. If you are under 18, or need support to complete this form, this section should be filled in and signed by your parent/guardian/nominated support person.
Your name*

First NameLast Name
Relationship to person (if applicable)
Date of birth of person sharing their story*

DayMonthYear
Address*

Street Address

Street Address Line 2

SuburbCity

Post code
Email address*
example@example.com
Mobile/telephone number*

Area CodePhone Number
- I understand that I and/or my child do not own the copyright or have any rights of ownership or other claims over the photographs, video or audio recordings, quotes and information about me or the child for whom I have parental responsibility.
- I understand that any information about myself and/or the child for whom I have parental responsibility will only be used for the stated purposes of this form.
- I understand that I can withdraw my consent at any time by contacting CCS Disability Action. If I withdraw my consent, CCS Disability Action will no longer use any information I have provided previously. However, I understand that any published materials that already include my information cannot be recalled.
I agree with the terms and conditions and confirm that the details provided are accurate.

I agree
Date of agreement

DayMonthYear
Do you want a copy of your submission?

Yes

Communication consent form