FILMING/PHOTOGRAPHY CONSENT FORM
Southwark Council is asking your permission to publish still photographs or moving images of you or your child for electronic and printed publication, as well as film, TV and any other media. Please note that images on web sites can be viewed worldwide.
Southwark Council abides by the Data Protection Act, so photographs/images of you or your child will only be used with your knowledge and in the correct context.
| Name of participant | MERVELEE MYERS |
| If under 16, name of parent/guardian | |
| If staff – name of your organisation | Fight4justice |
| Job title (if member of council staff) | Mental Health & SEND Advocate |
| Are you a resident of Southwark? | Yes / No Since December 2000 |
| Your contact Details | Email address: ratty.nembhard1956@gmail.com & rattynem@btinternet.com |
| Phone number: 07950618083 | |
| Date | 17/05/2021 |
| Title of the Campaign / purpose | COVID-19 Vaccine 2021 This photo/video is to help Southwark Council and its partners encourage the uptake of the COVID-19 vaccine. |
| Quotes to accompany the photo | To be decided from Video |
| I give Southwark Council permission to publish photographs or use film or video bearing my image or the image of my child. The film or photograph will be used in the context of promoting the Council or services provided by the Council and may be kept for use in subsequent promotional films or publications made by the council. | X Yes | No |
| I am happy for my photograph, quote or video bearing my image or the image of my child to be shared with NHS South East London CCG to help promote the covid-19 vaccine campaign. | X Yes | No |
| I am happy for my photograph, quote or video bearing my image or the image of my child to be shared with Community Southwark (Registered charity (no. 1 105835) to help promote the covid-19 vaccine campaign. | X Yes | No |
| I give permission for it to be disclosed that I am a Southwark resident (if applicable). If you say yes, it may appear on screen. | Yes X | No |
| I also give permission for my name and job title to be disclosed. If you say yes, it may appear on screen. | X Yes | No |
| I am happy to be contacted by Southwark Council if they would like to seek any further information from me. | Yes X | No |
| Xo I have read and understood the privacy notice | ||
| Signature of participant (or parent/guardian): MIMyers |
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