Media Consent Form – Youth Name First Last Name of Agency at which you are enrolled:Big Brothers Big Sisters of London and AreaI 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 me 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.HiddenConsentI 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 me 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 YouthDate MM slash DD slash YYYY Note: Confidentiality Concern Please check here if you do not want your picture used or if you have a safety concern. SignatureDate MM slash DD slash YYYY 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.HiddenNote: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.PhoneThis field is for validation purposes and should be left unchanged. Facebook Twitter Google+ LinkedIn
