Media Consent – Child/Youth

Name of Child/Youth(Required)

First Last

Name of Agency at which child/youth is enrolled:(Required)

I hereby consent to Big Brothers Big Sisters of Canada (National Office) and its associated member Big Brothers Big Sisters of London and Area the use of any photographs, audio and/or video recordings of my child or youth as taken or produced by media personnel and/or National Office or Local Agency staff at recreational events or match outings, or otherwise authorized by the National President & CEO, local agency President/Executive Director/CEO or Board of Directors, and that this media may be used by Local Agency and/or by the National Office for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and digital media, (such as the local agency websites and social media). Photographs or video productions may also be shared with community and school partners for program promotion.

Signature of Parent/Guardian

Date

Note: Confidentiality Concern

Please check here if you DO NOT want your picture or your child’s picture used or if you have a safety concern.

Signature of Parent/Guardian

Date

Note: It is your responsibility to notify the office if the status of this consent changes. By clicking submit, I consent to the collection of this personal information in accordance with Big Brothers Big Sisters of London and Area's Privacy and Confidentiality Policy.

Note

SMS Verification(Required)