VICTORIAN CURRICULUM
AND ASSESSMENT AUTHORITY
Level 1, 2 Lonsdale Street, Melbourne VIC 3000, Australia
TELEPHONE +61 3 9032 1700 FASCSIMILE +61 3 9032 1799
EMAIL [email protected] WEB www.vcaa.vic.edu.au
Permission for Personal Representation
COLLECTION NOTICE
The Victorian Curriculum and Assessment Authority (VCAA) is a statutory authority continued under the Education and Training Reform Act 2006 (Vic). The VCAA collects the information requested in this
form, which includes personal information as defined in section 3 of the Privacy and Data Protection Act 2014 (Vic), for the purposes of obtaining your approval to use your name, or image, or work in
conducting and publicising the education related program stated herein. If the requested information is not provided, your approval for this use will not be assumed. The information collected in this form
will be disclosed to relevant VCAA employees and/or contractors for and in connection with the abovementioned purposes. When an individual’s personal information is provided to the VCAA by a third
party, the VCAA requests that the individual is made aware their personal information will be or has been provided to the VCAA, the purpose/s for which it will be or was provided and to whom it is likely
to be disclosed. Unless consent from the relevant individual is provided, or the VCAA is authorised or required by law to do so, the VCAA will not use or disclose the personal information collected in this
form except in connection with the abovementioned purposes. An individual may request access to personal information the VCAA holds about them, if any, and request its correction if inaccurate. To do so
please contact the Communications Unit directly by phone on (03) 9032 1627, or via email: [email protected]. The VCAA Privacy Policy can be found at www.vcaa.vic.edu.au/Pages/aboutus/policies/
privacypolicy.aspx.
Thank you for agreeing to give the Victorian Curriculum and Assessment Authority (VCAA) permission to make and use representations of you. These
Representations may include photographs and film and sound recordings of you as specified on page 2. Please read this form carefully before signing
it. Please ask the person who gave you this form to explain any item you do not understand. Print your personal details in CAPITAL letters. If you are
under 18 years of age, a parent or guardian must also sign this form.
PERSONAL DETAILS
Family name
First name
Address
Date of birth
Telephone(
State
Postcode
State
Postcode
D D / M M / Y Y Y Y
)
Mobile
(business hours)
SCHOOL DETAILS (IF APPLICABLE)
School name
Address
Contact name
DATA\FORMS\PermissPersRep.indd
Telephone(
)
Page 1 of 2
The VCAA intends to make the following Representations of you
OFFICIAL USE ONLY
VCAA to complete details of the type of representation being made (films, photos, sound recordings). Specify digital resolution (if possible) and event
details, including the dates of making these representations.
VCAA contact name
M I R A N D A
P I C T O N - W A R L O W
Telephone ( 0 3 ) 9 0 3 2 1 6 3 1
Project or program VCE SEASON OF EXCELLENCE 2017
Event/s TOP ACTS, TOP ARTS, TOP CLASS, TOP DESIGNS, TOP SCREEN
Event date/s
1 M
2 / Y2 Y0 Y1 Y6 to D3 D1 / M
1 M
2 / Y2 Y0 Y1 Y7 (if applicable)
0 D1 / M
D
Types of recording PHOTOGRAPHY, FILMING, AUDIO RECORDINGS,
Recording sessions
At events, bring in days, concerts, exhibitions and other associated Season activities.
DECLARATION
Igive permission for the VCAA to make and use the above listed Representations, without remuneration, in accordance with the following terms:
1.
The VCAA may reproduce and communicate Representation/s of me in VCAA publications and resources (created in any media or format), including public
distribution online via websites or services controlled or authorised by the VCAA.
2.
The VCAA may alter the Representation/s of me (e.g. by cropping images) to suit the functionality and requirements of its resources and publications.
3.
The VCAA may provide Representation/s of me to third parties, for their use (including reproduction and communication online) in accordance with these
same terms and in connection with educational initiatives, including the promotion of such initiatives. I understand third parties may include schools and
other educational bodies, other government authorities, the sponsors and partners of VCAA initiatives and media outlets.
4.
The VCAA will own the Intellectual Property in any Representations it creates, or commissions, of me.
5.
Where I supply the VCAA with Representation/s of me, I grant, and warrant that I am authorised to grant, to the VCAA and any third party referred to in
paragraph 3, a non-exclusive licence to reproduce and communicate those Representations, free of charge. I further agree that the VCAA will not return the
Representation/s supplied by me.
6.
The VCAA may include my name and school/institution in a caption relating to Representation/s of me, but I understand that the VCAA reserves the right
to omit captions. I agree that the VCAA may provide my name and school to third parties referred to in paragraph 3, where these parties seek to provide a
caption for Representation/s of me.
7.
Where Representations of me also specifically record or capture copyright material owned by me, I will provide the separate copyright permission
documentation required by the VCAA.
8.
This permission remains in place unless I notify the VCAA in writing, addressed to the Communications Manager, VCAA, Level 1, 2 Lonsdale Street,
Melbourne 3000, that I no longer want the Representation/s of me to be used by the VCAA or any third party. I understand the VCAA will do what it
reasonably can to fulfil my request and I accept that it may not be possible to withdraw the Representations already in circulation.
9.
I confirm that I have had the opportunity to read and ask questions about this permission form.
The VCAA agrees that it will use its best endeavours to ensure Representations of you are not used in any way that may be deemed adverse or
defamatory to you.
Signature of person
making this declaration
Date / / PARENT OR GUARDIAN DETAILS
DATA\FORMS\PermissPersRep.indd
If you are under 18 years of age, a parent or guardian must complete this section and sign on your behalf.
Name
Relationship
to student
Signature
Date / / Page 2 of 2
PRINT