Media Consent Form

Why we are asking for your consent

We would like your permission to collect, use and share images, video, audio recordings and quotes that feature you.

These may be used to promote our services, share community stories, and inform stakeholders about our work.

Your Details

First Name *

Last Name *

Preferred Name (optional)

Email Address (optional)

Are you 18 years or older? *

Yes No - a parent or guardian will need to sign at the end. Please continue.

What you agree to

If you tick the box and sign this form, you allow NRH to use:

Photographs
Video footage
Audio recordings
Written or spoken quotes
Your name (optional - you can choose below)

These may be used in the following formats:

Social media
Website content
Printed and digital materials (posters, newsletters, internal & external displays)
Reports and presentations
Media releases and/or communications with stakeholders

Do you consent to your name being used? *

Yes First Name onlyNo - Please keep me anonymous

How your media will be stored

All media is stored securely by NRH. Only authorised staff or contractors will have access.

Media may be kept up to five (5) years, unless you withdraw your consent sooner.

Your Rights

You can:

Ask us to stop using your image, audio or quotes at any time.
Withdraw consent by getting in touch with us (please refer to our Contact Us page).
Request copies of the media we hold about you.
Choose which types of media you do or do not consent to (below).

Please tick the media you agree to *

PhotosVideoAudioQuotesAll of the above

Withdrawal of consent means we will stop using your media in future content. We cannot remove materials already published, printed or shared publicly.

Parent or Guardian Details (if under 18)

Parent/Guardian Name *

Relationship to minor *

Confirming your Consent

I understand this form and agree to the use of my media as I have selected above *

Signature *

Draw signature|Type signatureClear

Date *

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