This document may be used only when the client has capacity to give informed consent. If capacity is in doubt, then the case should be reviewed in conjunction with the CHANGE AHEAD/IMCA Safeguarding policy.

I hereby give consent to Penny Croal at Change Ahead to record Video and Audio.

This authorization grants permission to use your image (still or moving) and/or your spoken words in perpetuity for educational purposes.

By signing this document, you agree:

  1. To allow the recording of your image and voice (e.g., photographs, audio, or video).
  2. To distribute your image or recording in any medium, be it print or electronic form, which may include the Internet.
  3. To grant permission to other entities to reproduce the images or recording for educational purposes.
  4. That there is no reimbursement for the right to take, or to use your photograph or video or recording.

I have read and fully understand the intent and purpose of this document and am signing it without reservation.

I understand that refusal to sign this form will not affect my eligibility for receiving services at this agency.