Media Consent Form

Experts in hearing and speech therapy

Media Consent

By submitting this form, I give Hear and Say Limited (Hear and Say) permission to:

Create, adapt, use, publish, retain, or produce my image and/or my child’s image;
Use my name, and/or my child’s name and age/date of birth;
Use my image and/or any recordings of me and/or of my child, which may include photographs, videos, film, or sound recordings; and
Use my image and/or my child’s image for promotional purposes across various media, including but not limited to newspapers, testimonials, electronic direct mail, magazines, brochures, flyers, posters, social media, television advertisements, radio advertisements, videos or other multimedia and websites including the Hear and Say website.

By submitting this form, I understand:

That Hear and Say is under no obligation to provide any form of draft material to me for review or approval prior to use.

By submitting this form, I acknowledge:

That there is no financial payment or compensation relating to these activities; and
Agree that Hear and Say will own the print or form of digital or recording.

Your name and surname(Required)

First Last

Phone

Your child's name and surname:

First Last

I want to receive information about offers, services, products, events, and fundraisers that Hear and Say thinks may be of interest to me or surveys including by mail, email, SMS, social media, or other forms of communication. I understand I can unsubscribe from these communications at any time.

I acknowledge that I have read the Privacy Policy.

Consent(Required)

I understand, acknowledge, and agree to be bound by the terms set out in this form.

Name

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Date

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