Model Release Consent Form - Havens Hospices

Media Policy and Consent for Publicity Form

At Havens Hospices, our specialist care is free but we can only exist because of the support and generosity of the community. Together, we’re ‘Making every day count.’

Terms of Use

Havens Hospices may share your photo/interview for promotional purposes across a range of platforms and materials for up to five years including:

Havens Hospices social media pages including Facebook, Twitter, Instagram, YouTube and LinkedIn
Trading in-store promotional materials
Promotional video
Charity publications such as newsletters, supporter letters and reports/applications for trusts and grants
Media press articles
Havens Hospices website (www.havenshospices.org.uk) and eNews
Fundraising communications, including; talks, presentations, thank you letters, leaflets (including Lottery, Legacies, events and In Memory materials)

Location of photoshoot
Name*
First Last
Instagram Account (@)
Date of birth*
DD slash MM slash YYYY
Address
Street Address Address Line 2 County Post code
Email*
Declaration
I have read and understood the above and I give permission for Havens Hospices to use my photos/interview for up to five years.
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*
DD slash MM slash YYYY

Havens Hospices Model Release Form

Media Policy and Consent for Publicity Form

Declaration