POPDHH - Media Consent and Release Form

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The personal information on this form is collected by POPDHH in accordance with BC Freedom of Information and Protection of Privacy Act (FOIPPA). The information will be used for the purpose of determining the educational needs of the student, and will be protected under FIOPPA. This form has no expiration date, but an be revoked at any time.

Questions about collection and use of this information can be directed to our office.

Please note: Absence of media consent will not preclude the POPDHH from service provision per our Program Mission and Mandate.

Student's Name *

Student’s Date of Birth *

YYYY

School District *

School Name *

TDHH/Main Contact *

TDHH/Main Contact's Email *

Please double check for typos as this email will be used to send you a confirmation

Parent(s)/Legal Guardian(s) *

Parent(s)/Legal Guardian(s) Email *

Please double check for typos as this email will be used to send you a confirmation.

Home Address and Phone Number *

Consent *

As a legal guardian of this student, I hereby consent to the use of photographs/video recordings taken during the course of the school year(s) for educational purposes

I also consent to the use of my child's photo or video recording for publicity and promotional purposes, including publications, presentation or broadcast via newspaper, internet or other media sources

I do this with full knowledge and consent and waive all claims for compensation for use, or for damages

Required

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