Pledge Video Consent Form
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Monitoring
Some of this section is optional, but by completing this section will enable us to ensure the Leicester HIV Testing Week campaign pledge video is representative of Leicester.
What's your pronouns? *
Age *
Where do you live? *
Which of the following options best describes how you think of yourself?
Clear selection
Which of the following best describes how you think of yourself?
Clear selection
Is your gender identity the same as the gender you were given at birth?
Clear selection
Which of the following options best describes how you think of yourself?
Clear selection
Granting permission
I, the undersigned, do hereby grant permission to TRADE SEXUAL HEALTH and MIDLANDS PARTNERSHIP NHS FOUNDATION TRUST, to take, edit, alter, copy, exhibit, publish, distribute and make use of my uploaded video content to be used in and/or for any lawful promotion materials including, but not limited to newsletters, flyers, posters, advertising, press kits, websites, social networking sites and any other print or digital communications. Furthermore, I understand that no royalty, fee or other compensation shall become payable to me by reason of such use. *
Signature *
Full name *
Name to be displayed in the campaign video *
Todays date *
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