Media Release Permission Form
This information is entirely confidential.
Full Name of Parent/Guardian completing this form
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First Name
Last Name
Full name of child receiving services from the BC Family Hearing Resource Society:
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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?
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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.
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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:
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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?
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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
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Month
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Day
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Date
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