This permission form allows an individual to consent to the use of their photographs, video, or audio content by an institution for internal purposes and educational dissemination. The individual can agree or not agree to having their multimedia content used to aid curriculum planning and for other purposes specified by the department or program. If consent is provided, the individual must print and sign their name, and include the date and their email address and department or program, if applicable.

1. Permission form
Institution name
…………………………………………………………………………………
Department name:
…………………………………………………………………………………
Permission form – use of photographs, audio or video
FORM FOR INDIVIDUAL CONSENT
I consent to the use of photographs/video/audio of myself, (delete as appropriate) taken by
members of the programme design team on behalf of the institution, bring used internally and for
educational dissemination. These images/video/audio are for use for the following purpose(s):
Purpose(s)
To aid curriculum planning
…………………………………………………………………………………
(insert purpose here)
…………………………………………………………………………………
(insert purpose here)
…………………………………………………………………………………
Agree
Do
not agree
PRINT INDIVIDUAL’s NAME: ………………………………………………………………………………………….....................
SIGNATURE:…………………………………………………………………………………. DATE:……………………………………….
EMAIL: ………………………………………………………………………………………………………………………………………………
DEPARTMENT/PROGRAMME (if applicable):……………………………………………………………………………………..