Image permission form

I,

First Name: *

Last name: *

give permission to use my name/photograph/ image/audio recording/video recording and likeness in all forms and manner (“My Image”) for the purposes of advertising, media publicity, publication, general display or for any other college purposes in whole or in part, including but not limited to publication on internet web sites, broadcasts and any other publications as released to or by Kiama Community College Ltd. I waive any interest that I may have in the copyright to "My Image" now or at any future time and acknowledge that I am not entitled, nor shall in the future be entitled, to receive any payment or consideration in respect of it and agree to make no claim against Kiama Community College Ltd for any payments for the Publication of "My Image". I forever waive any right to inspect or approve any Publication of "My Image" by Kiama Community College Ltd. I release and indemnify Kiama Community College Ltd from any loss, damage, costs, expense, or claim (including consequential loss) connected with the Publication of "My Image", including action for defamation, libelous material, breach of privacy, or copyright

I understand I can withdraw the above consent at any time by advising Kiama Community College Ltd in writing via mail to: 7-9 Railway Parade, Kiama NSW 2533, Australia or via email to: communications@kcc.nsw.edu.au

For Aboriginal and Torres Strait Islander People Only: Continuing reproduction after deceased

I understand that KCC Ltd. will publish my image with the following statement: "Please be aware that this publication/resource may contain the names and/or images of Aboriginal and Torres Strait Islander people who may now be deceased."

YESNO

I give ongoing permission for my name and image to continue to be reproduced after my death. [alternatively, record in notes below whether the permission is ongoing, restricted to a particular person/company or for viewing in a particular area]

YESNO

Notes:

A mourning name should accompany any reproduction of images after my death. My mourning name is [insert below] And please contact the relevant contacts listed below for an appropriate name.

Please let us know if there are other relevant contacts (e.g. Land Councils, Elders, Relatives) you would like contacted [list below]:

For Everyone to complete

Phone: *

Email: *

Home Address: *

Signature: *

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If the participant is under 18 years of age. I, [insert name below] as parent or legal guardian of the above named individual, have also read this form and give my approval of its terms.

Guardian Signature

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Date: *