NSW Health Multi-Media Consent Form Personal DetailsName(Required) First Last Email(Required) Phone(Required)Address Street Address Address Line 2 City State Post Code ARE YOU A PATIENT OR RECEIVING SERVICES/TREATMENT FROM NSW HEALTH? Yes No Name of the Facility ARE YOU AN EMPLOYEE OR SERVICE PROVIDER TO NSW HEALTH? Yes No Name of the Workplace or Facility Workplace or Facility Address Street Address Address Line 2 City State Post Code DO YOU REQUIRE APPROVAL TO PARTICIPATE IN THIS ACTIVITY? Yes No Name & Role of Approver Are you of Aboriginal or Torres Strait Islander Background?(Required) Yes No This consent form authorises the person’s likeness and voice, and any activity undertaken by the person in relation to this release (including artistic or creative activity) to be recorded/edited/reproduced/broadcast/ published/disseminated/distributed/via electronic and/or other form, to be shown and/or heard in public via radio, television, newspaper, magazine, Internet or other means, to be used by NSW Health and other agencies of the Crown, subject to these terms and conditions. This consent form also allows NSW Health to upload to the NSW Health Image and Video Library.I acknowledge that I assign all rights, title and interest including copyright to NSW Health, and acknowledge that NSW Health is not obliged to use the multi-media material if it so chooses.Aboriginal and Torres Strait IslanderUnderstand I understand that NSW Health will publish my image with the following statement:Please be aware that this publication/resource may contain the names, images and/or voices of Aboriginal and Torres Strait Islander people who may now be deceased.Permission I give ongoing permission for my name and image to continue to be reproduced after my death. Alternatively, record here whether the permission is ongoing, restricted to a particular person/company or for viewing in a particular area Name & Image restriction details Mourning name A mourning name or Sorry Business name should accompany any reproduction of images after my death.My mourning name is Alternatively, please contact the relevant contacts listed below for an appropriate name:Mourning name contacts ConsentThe Multi-Media material may be used in perpetuity or for a time period From... To Type Name for Signature(Required) Date DD slash MM slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
