Consent for Collection and Use of Personal Information from an external organization Free Footie Soccer Society Free Footie is a totally free after school soccer program for kids in grades 4, 5 and 6. The league makes it possible for everyone to play, removing barriers such as cost, transportation and other challenges that may prevent kids from signing up for the “regular” city leagues. Our goal is to make sure the kids have fun, get active and learn as much as they want about soccer teamwork, leadership and respect. It’s organized by volunteers and costs approximately $40,000 to run the program for nearly 1,000 kids. All of that money goes to provide the kids with jerseys, shorts, shin pads, socks, goalie gear, medallions and transportation to and from games. We would like to take photos/video of your kids playing and having fun because it will help us show our sponsors that this is a program worth supporting. Finding sponsors is very difficult and photos/video will make a big difference. Please allow us to take photos/video so this program can happen again next year. Student Images ______________________________(school name) School is facilitating the Free Footie Soccer Society in requesting your permission to photograph, videotape and/or interview your child at Free Footie soccer practices, clinics, games and the year-end tournament that your child is playing in with their school. Free Footie will use these images for promotional materials (print publications and/or online). Images, video or audio recordings posted online may include, but are not limited to, public websites, blogs, podcasts, social media (i.e., Twitter, Flickr, YouTube, Facebook, etc.) and other emerging technologies. These audio and video images may be used for as long as they are relevant and valid. The student’s first or last name will not be used, but the school may be identified. You may revoke your permission at any time by contacting Dana Adams, volunteer board member of the Free Footie Soccer Society, at dadams@fieldlaw.com or 587-337-3118. Please note that images and clips posted on public websites may be available on the Internet indefinitely, even after they are removed from our website. The school will return this form to the Free Footie Soccer Society. Under the Personal Information and Protection Act, your permission is required for the above to take place. I understand that by completing this section I consent to having my child videotaped, photographed and/or interviewed and used for the above stated purpose(s). To be completed only if consent is given. Student’s Name: ___________________________ Grade: _____ School:___________________ (print first and last name)
Parent/Legal Guardian(s)’ Signature(s):____________________________ Date:_____________
IMPORTANT! PLEASE FILL OUT BOTH SIDES OF THIS FORM