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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<ul><li><p>Guidelines for National Consent Form for </p><p>Publicity/Filming/Photography </p><p>Document Type </p><p>Policy Document developed by </p><p>Valerie Kavanagh </p><p>Revision number </p><p>0 Document approved by </p><p>Kirsten Connolly </p><p>Approval Date </p><p>- Responsibility for implementation </p><p>All HSE Communications Staff </p><p>Revision Date </p><p>2yrs Responsibility for review and audit </p><p> Valerie Kavanagh </p><p>Draft or Final document </p><p>Draft version 1 </p></li><li><p> 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 </p><p>report etc. </p><p> Videos/dvds/audio productions Website/intranet/extranet/social media Recruitment information/ advertisements HSE Health Matters </p><p> 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 </p></li></ul>


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