PHOTOGRAPH AND VIDEO RELEASE FORM

I,

being the mother/father/guardian of

give permission for the use of his/her likeness in a photograph/video captured by CDH Australia for display purposes in both Australian and international media and on the CDH Australia web site, from this date until advised otherwise.

I acknowledge that my child/(ren) will be identified by first name only where a name is required.

I hereby certify that I am the parent/guardian of

and do hereby give my consent without reservation to the foregoing on their behalf.

(Parent/Guardian’s Name)

(Parent/Guardian’s Signature & Date)

Please note: You may withdraw your permission at any time by emailing information@cdh.org.au; however, the use of your child’s image in retrospective media cannot be removed. Withdrawal of permission will only apply from the date the request is lodged.