Media consent form

St Margaret’s Hospice Care use videos, sound recordings, photographs and interviews which may appear on our website, social media platform, in our leaflets, newsletters, exhibition displays, annual reports, campaign materials, brochures and in our local or national newspapers.

What is your connection with St Margaret's Hospice?

Name(Required)

First Last

I'm filling this form out on behalf of my child or next of kin

I’m filling this form out on behalf of my child or next of kin

Name of child / next of kin(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

By ticking the boxes I agree with their corresponding statement(Required)

I understand that I can withdraw my consent at any time

I understand how my consent may be used and that any consent I provide may be shared with third party media such as but not limited to, radio, press and TV.

Consent Agreement

I agree for photographs to be used

I agree for videos to be used

I agree for sound bites to be used

I agree for my name to be used

I agree for all information provided to be used

By ticking the boxes I agree with their corresponding statement

I am aware this consent will last a period of five years.

As St Margaret’s Hospice care’s printed promotional materials can remain in circulation for a long time, I understand it is not possible to recall these materials once distributed

I acknowledge the recommendation to make my family aware that I have allowed St Margaret’s to record my story/image and that I have referenced them within my story.

I understand that my content may be used multiple times, without restriction and without any compensation to me.

If there are any ways I do not wish any content/video/photographs/interview to be used I have detailed them here:

Signed:

Date:

Media Consent Form