Photograph Consent Form (Children) Permission Form – Digital/ photograph images and video recordings I hereby give permission and authorise the Provincial Grand Lodge of Durham to take, or use, digital, photographic and/or video images of a child in my care 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 above. 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. Child’s name.................................................................. I confirm that I am the parent/legal guardian* of the above named child and give permission for photographic images to be produced and used as outlined in this agreement. Your name...................................................................................... Signed.......................................................... Date ......................... Witnessed by .................................................................................. Signed.......................................................... Date ..........................
Office Use Only Image Date:
Case Ref: Photographer:
To comply with the Data Protection Act 1998, we need your permission before we can photograph or make any recordings of you or the person for whom you have responsibility. Please scan this form and send electronically to the Provincial Communications Officer, Paul O’Doherty. Email: paul.1@blueyonder.co.uk No publication can be used without this signed consent form.