Photograph Consent Form (Adults) Permission Form – Digital/ photograph images and video recordings I hereby give permission and authorise the Provincial Grand Lodge of Durham to take digital, photographic and/or video images of myself for the purpose of promoting its activities. I agree that the images can be stored and used, without my further permission on promotional materials produced by the Provincial Grand Lodge of Durham and its partners, both now and in the future, including on our website. I understand that I will not be paid for this now or in the future. I understand that I can withdraw my consent in writing at any time to the address below. In this case the Provincial Grand Lodge of Durham will not be able to withdraw material already in the public domain, but the Provincial Grand Lodge of Durham will not use the images in future new materials
Your Name...................................................................................... Signed..........................................................Date…......................... Witnessed by Name......................................................................... Witness signature......................................... Date……....................
Office Use Only Image Date:
Case Ref: Photographer: