Your Community Health Simple Consent Form

Your Community Health image consent form

Your Community Health puts photos and videos of people like you in our newsletters and reports, website, social media and flyers. They help us share our work with the community. This forms gives us permission to use photos and/or videos of you in our work. Please contact us at [email protected] if you would like us to stop using your photo or video.

Event details(Required)

I understand that Your Community Health may use photos or video of me in their work:(Required)

Yes

I consent to Your Community Health using photos or videos of me in the following places:(Required)

Anywhere (unrestricted use)

Newsletters, flyers, posters and reports

Website

Social media (Facebook, Instagram, etc.)

Date:(Required)

Name:(Required)

First Last

Phone:(Required)

Email:(Required)

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Identifying features (i.e. red top, blue glasses):(Required)

If you are under 18 years of age, does your parent/guardian consent?:

Yes

Parent/Guardian Name

First Last

Phone

Name

This field is for validation purposes and should be left unchanged.

Your Community Health image consent form

Search Your Community Health