Consent For CYP Art Exhibition

Name of child/young person taking part*

First Last

Date of birth*

Name of person cared for by Havens Hospices*

The child's relationship to the person cared for*

Contact details of person giving consent

Name

Title First Last

Address

Street Address Address Line 2 County Post code

Home phone number

Mobile phone number

Email*

Relationship to child/young person

I am happy for my young person's artwork to be displayed in the following exhibitions.

Select All
Little Havens - one day exhibition
Fair Havens - week long exhibition
Leigh Art Trail

Are you happy for us to include the following information on their artwork plaque?

Select All
First Name
Last Name
Age
Town
Name of person cared for by Havens Hospices
Relationship to person cared for by Havens Hospices

Are you happy for your young person to be featured in the media? E.g. social media/Echo/local news websites.

Yes
No

If yes, please complete our consent for publicity form too

Declaration

I have read and understood the above and I give permission for Havens Hospices to use the information and artwork in line with the above decisions. I understand artwork can be collected from Little Havens one week after the exhibitions you have consented to have finished. Artwork will be kept for a maximum of one month and recycled if not collected in that time.

Parent/Carer Full name – this will be used as your electronic signature*

Consent*

I agree that my full name in the field above will be used as my electronic signature

Date*

Havens Hospices Art Exhibition Form

Consent for Art Exhibition

Contact details of person giving consent

Declaration