Photo, video and story consent form
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Photo, video and story consent form

[ORGANIZATION NAME] would like to share photos, video and stories about our work so that more people understand it and support it. Please tell us what you're happy for us to use. Saying no, or ticking only some boxes, will never affect any help or service you receive from us.

About you

- Name: [NAME]
- Contact (phone or email): [CONTACT]
- Event or program: [EVENT OR PROGRAM AND DATE]

What we may use (tick all that apply)

- [ ] Photos in which I can be seen
- [ ] Video in which I can be seen or heard
- [ ] My first name
- [ ] My full name
- [ ] My story or quotes, as I have told them to [ORGANIZATION NAME]
- [ ] My story or quotes, only without my name
- [ ] None of the above. Please don't use my image, name or story.

Where we may use it (tick all that apply)

- [ ] Printed materials, such as newsletters, flyers and annual reports
- [ ] Our website
- [ ] Our social media accounts
- [ ] Reports and applications to funders
- [ ] News media, if a journalist asks us
- [ ] Other: [DESCRIBE]

What we promise

1. We will use your image, name and story only in the ways you have ticked.
2. We won't sell your image or story, or give it to anyone else to use for their own purposes.
3. We won't share your address, health information or other private details with your image or story.
4. We will keep this form on file for as long as we use the material, and for [NUMBER] years after.
5. This consent lasts until [DATE OR "YOU WITHDRAW IT"]. After that we will ask you again before any new use.

Changing your mind

You can withdraw or change your consent at any time by contacting [NAME OR ROLE] at [EMAIL OR PHONE]. From the date we hear from you, we will stop new uses and remove the material from our own website and social media accounts within [NUMBER] days. We can't recall printed items or posts that others have already shared.

Signature (adults 18 and over)

I have read this form, or had it read to me, and I agree to the choices I have ticked. I am not being paid for this consent.

Signature: [SIGNATURE]

Date: [DATE]

Parent or guardian (for anyone under 18)

I am the parent or legal guardian of [CHILD'S NAME], age [AGE]. I agree to the choices ticked above on their behalf.

- [ ] Please use my child's first name only, never their full name or school.

Parent or guardian name: [NAME]

Signature: [SIGNATURE]

Date: [DATE]

Where the child is old enough to understand, we will also ask them, and we won't use their image or story if they say no.

For office use

- Form received by: [NAME]
- Where the form is stored: [LOCATION]
- Photos, video or stories covered: [FILE NAMES OR DESCRIPTION]
- Review or end date: [DATE]
- Withdrawal received (date and action taken): [DETAILS]