Personal Data Consent Form/Model Release Form

ORGANISATION produces a range of published materials and web enabled information. To ensure that the Departmental message is engaging, motivating and inspiring we illustrate our range of materials with supporting words, text and images (moving and still) which we collect from individuals using our approved suppliers. Using personal data, enhances, motivates and inspires audiences to read and engage with our materials. The Department needs to collect consent prior to publishing personal data to ensure the rights of the individual are acknowledged, to maintain an audit trail and control the use of personal data. This minimises any risk to individuals and reassures individuals of the appropriate Departmental controls when consent has been given. The Department holds all personal data and consent in a secure environment and controls access and use of personal data for 5 years only, after which all personal data is securely destroyed. Individuals, their representatives or host organisations may wish to keep a copy of this form which can be sent to you on request.

I _______________________ (Print Name) hereby give my consent for the supplier (named above) the right to take part in the collection of personal data for ORGANISATION. I give my consent to the full use and reproduction of the material by the Department. I agree that the production I have contributed to may be exhibited in all of its media applications which promote or advertise the aims of the Department. This may include public and broadcast screenings. This will include the use by Departmentally approved organisations. The Department, without further consent use my name, likeness, biography and photographs of me and any recordings of interviews with me in advertising and publicizing the production in all media and formats. I hereby agree that my performance in title is not for any payment or deferred payment. I hereby grant the copyright and all other rights in respect of my performance. I hereby release and discharge the suppliers from any and all claims and demands arising out of or in connection with the use of my image, including any and all claims for libel or invasion of privacy. I am of full age and have the right to contract in my own name. I have read the above and fully understand the contents. This release shall be binding upon me and my heirs and legal representatives.

Personal Data Consent / Model Information Name ______________________________________________________________ Company (if applicable) ___________________________________________________ Address: ______________________________________________________________ ______________________________________Post/Zip Code: ____________ Phone: __________________ Email: ______________________________________ Signature: ______________________________Date:_______________
Should you require further information please contact XXXX

Supplier Details Company Name: XXX Address: XXX Phone: XXX Email: XXX Departmental Job Ref or Campaign Title or Purchase Order No: XXX