Without Prejudice Police, DBS Must Be Charge Charter Of Rights For Aiding LEYF In Abuse Rings, Discrimination Against Employees


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 organisationFight4justice
Job title (if member of council staff)Mental Health & SEND Advocate
Are you a resident of Southwark?Yes / No Since December 2000
Your contact DetailsEmail address: ratty.nembhard1956@gmail.com & rattynem@btinternet.com
Phone number: 07950618083
Date17/05/2021  
Title of the Campaign / purposeCOVID-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 XNo
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 XNo
Xo     I have read and understood the privacy notice
  Signature of participant (or parent/guardian): MIMyers  

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