CHD Network Media Consent Form

By completing this form you’re providing consent for ECHO and the CHD Network – Guys and St Thomas NHS Foundation Trust, Evelina London, The Royal Brompton and Harefield and their network of hospitals – to feature your photograph to promote the CHD network’s services supporting children and young people with heart conditions and their families.

Your photo may be used at events, online, through TV and radio and in print. Your involvement is essential for ECHO and the CHD Network to show the impact of ECHO and the CHD Network’s services and generate further support. Thank you.

Are you over 18? If you are under 18 you will need a parent/guardian to complete this form.

Over 18

Under 18

Full names of people being photographed *

Telephone: *

Email: *

Address: *

If child is under 18 please give date of birth:

Your relationship to the child:

Description of you and your child to help us identify you in photos: *

Please state here if there are any ways in which you do NOT want us to use photo(s) / video footage of you or your child:

Please read the below statements and tick each box to confirm your agreement.

Use of your photos *

I have agreed to be photographed/filmed/recorded and/or agreed for my child to be photographed/filmed/recorded.

I give ECHO and the CHD Network permission to use the photograph(s)/video/recording in which I/my child appear on the understanding that they will only be used in an appropriate manner and to support the work of the CHD Network.

I agree that any photographs and video may be kept on file for future use.

Are you an ECHO member? *

Yes

By ticking this box, I confirm that all the information provided is true and accurate and I am happy for my photographs to be shared.

Consent *

I agree

Captcha *

reCAPTCHA is required.

Data protection statement

Data protection statement

Other than as specified above, the information that you give us here will only be used to contact you about these photo(s) and only shared and accessed within ECHO, GSTT, Evelina London and RBH teams. For more information on how ECHO use your data see our Privacy Policy on our website. If at any time you would like us to stop using photos of you/your child(ren) you can contact us.