Media consent form

We would like to use the pictures, video footage or audio recordings we have taken of you to promote NCHA and the range of services it offers to support people in the East Midlands.

Please complete this form to give us permission to use the photos, video footage or audio recordings we have taken of you. You can also use the form to give us permission to use words or pictures that you have supplied to us.

NCHA acts as the Data Controller for the media you give us consent to use. Our privacy statement outlines the standards we follow to manage and protect your data. It also includes our contact details and information on how to contact us with questions.

About you

Your name: *

Your email address: *

Your address: *

Are you giving permission on behalf of someone else? *

Yes, I am giving consent on behalf of someone else

If so, please tell us your relationship to that person: *

Family member/friend

Support worker, social worker or similar

Other

If you're a support worker, please tick this box to confirm that the customer has the mental capacity to give consent.

Their name: *

Their email address:

Location or event

Where were the pictures, video or audio taken? *

What type of event was it?

Information event/open day

Scheme opening

Start on site

Conference

Other

On what date did it take place?

Your permission

Once you are happy with the information entered above, please tick the box and submit the form.