Image Permission Form
Name of organisation/artist
Project/activity/event title
(DCA-funded projects only)
- Funding program and category
- Application Reference Number
17/GA/
Key contact name
Contact number
email address
Image Credit/Caption Format Guide
Performance
<Name of pictured performers/artists> (L-R), in <title of performance> by
<artist name/producer/company> at <event/festival>, <town/city/>;
<month, year>. Photo by <photographer’s name>.
Artwork
<name of artwork>, by <artist name>, at <exhibition and/or event>;
<town/city/>; <month, year>. Photo by <photographer’s name>
Audience or
participants
<Description of persons pictured, ie. workshop participants>, at
<exhibition/event/festival>;<town/city/>; <month, year>. Photo by
<photographer’s name>.
Activity
development
<Description of subject/persons pictured>, < description of activity being
undertaken>; <name of project/performance/event etc> by <artist name
if relevant>; <place name/town/city/>; <month, year>. Photo by
<photographer’s name>.
Please provide a caption for each image, using the above as a guide, to allow us to properly
credit your images wherever used by DCA in digital, web and print mediums.
IMAGE 1
Image file name
Caption (please use the format guide)
IMAGE 2
Image file name
Caption (please use the format guide)
IMAGE 3
Image file name
Caption (please use the format guide)
IMAGE 4
Image file name
Caption (please use the format guide)
IMAGE 5
Image file name
Caption (please use the format guide)
IMAGE 6
Image file name
Caption (please use the format guide)
Image Permission Form
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Terms and Conditions
1. The grantor of this licence (Grantor) gives the State of Western Australia, through the
Department of Culture and the Arts (DCA) a perpetual, irrevocable, worldwide, royaltyfree licence to use the images listed on the attached form (Images) for the purpose of
promoting any of DCA’s programs or policies or for any other printed or digital
publication issued by DCA. Where DCA wishes to use the Images for any other purpose,
DCA will request further permission.
2. DCA will have the right to reproduce, publish or otherwise communicate the Images in
a printed or digital format (including but not limited to reproducing the Images on
DCA’s website) and may alter, crop or manipulate the Images in a reasonable manner.
3. Where the Grantor is not the same person or entity as the image copyright holder, the
Grantor hereby warrants that the Grantor has obtained all appropriate licences and/or
permissions to sign the attached form and grant this licence.
4. Where the subject(s) of the Image is a person or persons, the Grantor hereby warrants
that they have obtained the consent (if required), of any such persons (or a parent or
guardian where the subject is a child or children), to use the Images in the manner
contemplated by this licence.
5. Where the Grantor is an entity, the person signing the attached form on behalf of the
Grantor hereby warrants that he or she is authorised to grant this licence on the
Grantor’s behalf.
6. Where any permissions, authorisations or licences have not been obtained in
accordance with paragraphs 3, 4 and 5 above, the Grantor agrees to indemnify DCA
for any loss sustained by DCA in relation to any unauthorised use of the Images.
Declaration
☐ I confirm I have read, understood and accept the terms and conditions outlined above.
☐ I give the Department of Culture and the Arts a licence to use the images listed in
accordance with the terms and conditions outlined above.
Name
Signature
Date
Image Permission Form
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