Guidelines for National Consent Form for for National Consent Form for Publicity/Filming/Photography Document Type Policy Document developed by Valerie Kavanagh Revision number

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    04-Mar-2018

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Guidelines for National Consent Form for Publicity/Filming/Photography Document Type Policy Document developed by Valerie Kavanagh Revision number 0 Document approved by Kirsten Connolly Approval Date - Responsibility for implementation All HSE Communications Staff Revision Date 2yrs Responsibility for review and audit Valerie Kavanagh Draft or Final document Draft version 1 Publicity/Filming/Photography Consent Form: For office use only: Insert name and caption of photo/ dvd/audio production / film clip (include where photo/dvd/audio production/ film clip was taken) . Name of client/resident/patient ______________________________________________ This photograph/film/audio production will only be used for Health Service Executive purposes that may include: Information literature/publications, including print media, posters, leaflets, booklets, HSE annual report etc. Videos/dvds/audio productions Website/intranet/extranet/social media Recruitment information/ advertisements HSE Health Matters It is the intention of the Health Service Executive Communications Division that the photos/dvd/audio production are used appropriately and sensitively. Please indicate your consent on your own behalf (and on behalf of your child if applicable) for this filming/photography/publicity and that you fully understand the reason for the photography/filming/audio by signing below. You also give permission for the image and likeness of you/your child to be distributed to national, regional and local print and online media and medical trade magazines. I agree that no fee will be made to me or my child in payment for participation in this photocall/filming/audio session or in relation to images/film/audio carried in any of the platforms described above. Name.. Address.. Tel/Mobile...EmailDate.. Please return a copy of this form to Communications Division, Health Service Executive. Address.. Tel/Mobile...Email

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