Media Consent – Mentee

MEDIA CONSENT FORM – CHILD/YOUTH

Name of Parent / Guardian(Required)

First Last

Name of Child / Children(Required)

First Name

Last Name

Multiple rows can be added for additional children by clicking the blue + found on the right of the screen

Date(Required)

I, the parent / guardian of the above mentioned young person, hereby consent to Big Brothers Big Sisters of Canada (National Office) and its associated member Big Brothers Big Sisters agencies (Dufferin and District) the use of any photographs, audio and/or video recordings of myself as taken or produced by media personnel and/or National Office or Local Agency staff at recreational events or match outings, or otherwise authorized by the National President & CEO, local agency President/Executive Director/CEO or Board of Directors, and that this media may be used by Local Agency and/or by the National Office for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and digital media, (such as the local agency websites and social media). Photographs or video productions may also be shared with community and school partners for program promotion. I further waive any claim which I may have against Big Brothers Big Sisters of Canada and its associated member Big Brothers Big Sisters agencies arising from the use of such photographs, audio and/or video recordings of myself, as aforesaid. This consent and waiver shall remain in effect unless otherwise revoked

Yes, I give consent

Confidentiality concern

Please check here if you do not want your picture or your child’s picture used or if you have a safety concern.

Signature(Required)

Note: It is the parent/guardian’s responsibility to notify the office if the status of this consent change

Comments

This field is for validation purposes and should be left unchanged.

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