Fillable Printable Model Consent Form Template

Model Consent Form Template

MODEL CONSENT FORM

This form needs to be completed and signed by each person (or the parent/legal guardian)

who is being recorded. It may not be appropriate in all circumstances.

VENUE………………………………………………………………………………………………………………..

DATE……………………………………………………………………………………..…………......................

NAME OF PHOTOGRAPHER/CREATOR OF RECORDING………………………………………..……….

NAME OF RECORDING………………………………………………………………………………………….

This form is to be signed by students, staff, formal visitors and/or other subjects, being recorded and/or

photographed or filmed [please delete as appropriate], or the parent/legal guardian of the young person if

below the age of 18. The purpose of this form is to seek consent for the photographs and/or films and/or

recordings [please delete as appropriate]to be taken and subsequently to be used in a number of media,

including print and the web by[insert name of institution/s]. [insert name of institution/s] in turn offers a

commitment to only allow said pictures and recordings to be used appropriately and sensitively.

I, the undersigned, consent to the use of my image and/or audio and/or visual recordings [please delete as

appropriate] being used and reproduced by [insert name of institution/s] under a Creative Commons [insert

the type of licence here, making sure NOT to specify the version number or the jurisdiction] Licence.

I understand that copyright in the image and/or recordings will be retained by [insert name of institution/s or

the name of the entity retaining the rights].

Under the terms of the Data Protection Act, 1988, personal details of those taking part and recorded on this

form will be used for the purposes of this project and are never made available to third parties.

I require/do not require that my name is removed/retained in association with the shots and/or recordings

[please delete as appropriate]

FULL NAME AND TITLE _____________________________________________________

FULL NAME OF PERSON BEING FILMED/RECORDED/PHOTOGRAPHED [please delete as

appropriate]_____________________________

NAME OF ORGANISATION___________________________________________________

CONTACT TELEPHONE_____________________________________________________

EMAIL ADDRESS __________________________________________________________

SIGNED ___________________________________DATED_________________________