Consent Form - St Richard's Hospice

GIVING PERMISSION TO USE PHOTOGRAPHS, FILM AND WORDS

St Richard’s Hospice is an independent charity caring for patients with a serious progressive illness and supports their families. Photographs, films and stories are really powerful ways of raising awareness and funds for hospices and showing people how they benefit patients and their loved ones.

You should only agree to us using your photo/film/words if you feel completely happy with us doing so and you are under no pressure or obligation to sign.

How we use your photos/film/words

We may use your photos/films/words to publicise St Richard’s Hospice care, services, fundraising and shops in newspaper articles, on social media such as Facebook/Twitter/Instagram; printed materials, electronic communications, presentations and other media such as websites and social media sites.

If appropriate, we recommend you consider the feelings of your next of kin and tell them that you have allowed us to take and use your photo/film/story and inform them that they can contact us at any time to stop using your photo/film/words again.

Remember that once an article is published and in circulation (for example a newspaper or on the internet including social media) it may be copied and used by others. If you or your next of kin ask us not to use the photo/film/words in future we will not do so and will do our best to stop others doing so, but we cannot guarantee it. The photo/words may still be featured on the internet/ printed materials that are already in circulation.

About the photos/film/words

Reason for image*

For example, patient/family story/fundraising/volunteering/shops

Staff member involved

(if applicable)

Full name of person in the photo/film/story*

I agree use of:*

Full name
First name only

Does the photo/film feature anyone under 18?*

Yes
No

Additional permission for children under 18

Please provide contact details of any other legally responsible adult who needs to be asked for permission to use the photo/film/words if child is under 18, in addition to yourself.

Parent/guardian name

Phone or contact email

About you

Name

Address

Phone

Email

Your permission

I agree to the use of photo/film/words, as outlined above*

I have read and understood the above and I give permission for St Richard’s Hospice to store, publish, republish or otherwise transmit still or moving images and audio or words of myself/the child I am signing on behalf of.

Signature*

(Parent/guardian please give name and signature if child is under 18)

Today's date*

How would you like to hear from us?

Contact preferences

We’d love to get in touch from time to time to keep you informed about the work of St Richard’s Hospice and provide you with exciting updates on our care, news and ways you can get involved. Please tick the boxes below to indicate your preferences on how you want to hear from us.

Select All
Email
Text message
Telephone

No contact

We do not share your data or financial details with any third parties outside of essential processing. We will store the information on this form for proof of consent.