Image and Story Consent Form

Story and image consent form

Thank you for your interest in contributing to the promotion of Playlist for Life and the power of music. We want this experience to be positive for you and it is very important to us that you are comfortable with what we are doing and how we plan to use your contribution.

With your permission, we will keep in touch to keep you updated about your contribution and ensure you continue to be happy with the way we have used your image and/or story. This consent form is valid for three (3) years from signing, but you can get in touch with us at any time to change your preferences or withdraw your consent. 
The following sections should be filled in by the person sharing their story and/or image - if the person lacks capacity or is under 16, they should be supported by their guardian/parent and the form should be signed by their guardian/parent. 

Personal details
The details below are for office use only and will not be shared. If you lack capacity or are under 16, this section should be filled in and signed by your guardian/parent. 

  • I understand that I and/or the person sharing their story do not own the copyright or have rights of ownership or other claims over the photographs, videos, audio recordings, quotes and information gathered. 
  • I understand that any information about myself and/or the person sharing their story will only be used for the stated purposes of this form. However, Playlist for Life cannot guarantee or be held liable for use of this information or image by a third party. 
  • I understand that I can withdraw my consent at any time by contacting Playlist for Life. If I withdraw my consent, Playlist for Life will no longer use any information I have provided. However, I understand that any published materials that already include my information cannot be recalled. 
  • This consent applies for three years from the date below.