BCFH - Media Release Permission Form

This information is entirely confidential.

Full Name of Parent/Guardian completing this form *

First Name Last Name

Full name of child receiving services from the BC Family Hearing Resource Society: *

First Name Last Name

Do you give us permission to record and use any photos, video, audio, or social media posts of you and your family? *

Yes (select to choose which you would like to allow) No

I/We hereby voluntarily and without compensation authorize the use of the following media by the BC Family Hearing Resource Society of me/us and my/our child, along with any siblings that may attend sessions, groups or events. *

Photographs Audio/Video recordings Social media

I/We consent for these media to be used by the BC Family Hearing Resource Society in the following: *

General publicity Social media posts/campaigns Information brochures and pamphlets Education and training materials for professionals Education and training materials for parents/families

Would you like to be contacted each time any of the media (as indicated above) of you, your child, or your family is used? *

Yes No

By signing below, I provide permission for the BC Family Hearing Resource Society to use the forms of media indicated above for the purposes indicated above: *

By signing below, I confirm that I choose NOT to give permission for the BC Family Hearing Resource Society to use photographs, audio and/or video recordings, or social media of me/us and my/our child, along with any siblings that may attend the sessions. *

Today's Date

Date