Consent for Use of Photographic Images, Interview, Video and other Marketing Material (“Material”)

Consent for Use of Photographic Images, Interview, Video and other Marketing Material (“Material”)

The purpose of this form is to seek your consent for Kairos Prison Ministry Australia (KPMA) to hold and publish the Material in promoting its activities. Please read the KPMA Privacy Policy on our website at www.kairos.org.au/privacy-policy
My Details
Name*

First NameLast Name
Email*
A copy of this form will be sent to this email
Phone Number
Please enter a valid phone number.Format: 0000-000-000.
Address

Street Address

Street Address Line 2

CityState / Territory

Postcode
Details of Material
Description of material
Eg: Interview, photo, testimony, audio/video recording etc
Date material created

DayMonthYear
Date
My Consent
I, {name}, being at least 18 years of age, consent to KPMA using the Material in promoting its activities. I acknowledge that I will not be remunerated for that use and KPMA acknowledge that I can revoke its right to use the Material if I so wish.

It is noted that KPMA, in some circumstances, may need to vary or alter some of the Material, however, it would only do so where, in its opinion, the character and nature of the Material had not changed.
YesNo
Signature *

Sign with your mouse or with finger on touch screen or use the type option to use keyboard
Date*

DayMonthYear
Date

If you wish to make any restrictions on the use of your Material, please list them below:

My Details