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Please complete the form below to provide your consent.
Thank you for allowing North Western Melbourne Primary Health Network (NWMPHN) to film you or take your photograph.
By completing this form you give permission to NWMPHN to use, for communications purposes:
Your image may be used in print, electronic and digital media, including social media. Your consent allows the use of images by NWMPHN, and sometimes by third parties. Digital images can be seen by everyone and may be shared on social media.
A parent or guardian must sign this consent form if the participant is under 18 years of age.
Fields marked with an asterisk (*) are required.