Image consent form

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 digital or photographic image, film or sound footage; and/or
images, film or sound footage or artwork you have produced.

Where may your image be be used?

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.

Are you under 18 years old?

A parent or guardian must sign this consent form if the participant is under 18 years of age.

Form

Fields marked with an asterisk (*) are required.

Your name*

First Last

Are you signing this form for yourself or someone else?*

Myself
Someone else

Who are you signing this form on behalf of?*

Your organisation (if any)

Your email address*

Name or location of event*

Date signed*

Comments (if any)

CAPTCHA

Where may your image be be used?

Are you under 18 years old?

Form

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