Photography/Film Consent • Spread a Smile

Child/Young Person's Details

Full Name*

Date of Birth*

Gender*

Male
Female
Prefer not to say

Please select hospital from the drop down list*

Name of ward (if applicable)

If you are comfortable in sharing your condition please write here

If any siblings, family members or friends are featured in the photograph please provide their name here and age (if under the age of 18)

Parent/Carer Details

Your Name*

Relationship to Child/Young Person*

Your Email*

Your mobile telephone number*

Your Address

Consent

I give permission for Spread a Smile to share information about the child/young person named above and me, where such information involves taking and using any (i) photographs, audio clips, or films of the child/young person, and (ii) personal quotes and messages from either me or the child/young person, in order to publicise Spread a Smile’s work (including in Spread a Smile’s marketing materials, PR, Spread a Smile’s website and social media and other websites and social media and to share with our supporters). I understand and acknowledge that: - the child/young person’s name will not be given to media or public without my express consent, and - this permission will continue until I provide Spread a Smile with written notification of cancellation, after which any images, audio or videos will not be used in future publications but may continue to appear in publications already published, printed or in circulation.

I am happy for the child / children / young persons named above and I to be:*

Select All
Filmed or recorded
Photographed/use of my own photography

Identified by:*

Select All
Full name
First name only
In the child/ children / young person’s case, their condition
The city/county where we live

Online Consent

By entering your name and the date below you are giving your consent online. You have the right to withdraw your consent at any time. To do so, please email: admin@spreadasmile.org or write to: Spread a Smile, 51 Chalk Farm Road, London NW1 8AN

Your Name

Date