MEDIA CONSENT FORM

Media Consent Form

The East Dorset & Purbeck community is at the centre of everything we do at Lewis-Manning Hospice Care. Our message is much more powerful when we share first hand accounts of the challenges, successes and stories of our patients, families, friends, volunteers and staff. We hope that you will help us communicate our impact through videos, photographs and interviews. We use our videos, photographs and interviews for all our publicity which includes (but is not limited to); websites, social media, local/national newspapers, leaflets, newsletters, TV, exhibition displays, annual reports, campaign materials, brochures and for active use as part of a Bournemouth University Photography Project. These will only be used to promote our services and raise awareness of the work of Lewis-Manning Hospice Care. This consent form is for patients, volunteers, supporters, family members, friends, carers and staff. OUR PROMISE Your video/photograph/interview will be kept for active use for five years and this means that within the period of five years from the date of your signature, we may use your video/photograph/interview in any of our media channels. After this time has expired, your video/photograph/interview will be archived and will no longer be used on new materials we produce. Please be aware that once created, materials may remain in circulation for a considerable length of time. We also keep an archive of the hospice’s history for special occasions, anniversaries and events and may re-use your video/photograph/interview to illustrate our historical timeline. If at any time in the future you would like us to stop using your video/photograph/interview in new materials, or if after five years you wish the materials to be removed from our archive, we ask that you contact us to confirm this in writing. Your video/photograph/interview will immediately be removed from our files, but please be aware we will not be able to remove it from content already published and in circulation. Lewis-Manning Hospice Care cannot guarantee that any information given to third parties (e.g. radio, TV) will cease to be used after expiration of consent.

If there are any ways I do not wish my video/photograph/interview to be used I have detailed them here:

First Name

Last Name

Contact number (mobile or landline)

Service User

Yes

My role is

Staff

Patient

Volunteer

Other

I also agree to my full name being published in associated materials if required

Date

Signature

Sign Here

IF A PATIENT IS UNABLE TO CONSENT, OR THE INDIVIDUAL IS UNDER 18, A GUARDIAN OR NEXT OF KIN CAN COMPLETE THIS FORM INCLUDING THE GUARDIAN/NEXT OF KIN SECTION BELOW. By signing this form I confirm that I have the relevant authority to give permission on behalf of the individual above. Please print your full name

Contact number (mobile or landline)

Relationship

I also agree to my child/next of kin’s name being published in associated materials if required

Yes

Date

Signature