Photography and video consent form
We are gathering examples of teaching in Adult Community Learning to use for publicity and/or reporting on
the impact of the service. We would like your permission to photograph and/or record you, or someone for
whom you are responsible for, for possible inclusion in these materials.
What will happen to my image?
We will store your image/recording for up to four years. It may be used at any time during this period, and
copyright for the image will remain with us. After four years we will delete your image from our systems, or
contact you to ask for an extension of your permission.
We may also share images with our partner agencies for specific projects.
Will you use my name and address?
We may want to include your name when we use your image. However, your contact details will be kept
within the county council and will not be used for any marketing purposes. We may contact you to send you
a copy of the image if agreed, or to check details within the image.
Why am I being asked for permission for you to take photographs or film of someone else?
Where a child is under 16, or an adult is particularly vulnerable we ask for a parent, foster carer, other care
provider or a legal guardian to give permission on their behalf.
ACL Photo and Video Consent form 2016/17 V1
Thank you for giving your permission for Staffordshire County Council and/or its
partners to use your image or that of a child in your charge.
You can ask us to stop using your image on any literature that has not yet been printed, or on any of our
websites.
If you would like permanently delete the image from our files, please ring 01785 854014 or email
[email protected] , quoting IL1.
Or contact me directly: Clare Roberts, Teaching and Learning Advisor, [email protected], tel
0781 582 7037
For what purpose is this photo/video/recording originally being taken?
Who is the photographer?
Date
Consent
I give my permission for Staffordshire County Council to take and retain photographic and/or moving images
of me for use across all circumstances described on this form. I confirm that I have read and understood
these conditions.
Name of person being
photographed and/or filmed:
Signature:
Address
Postcode
Contact telephone
ACL Photo and Video Consent form 2016/17 V1
Email address