Video interview consent – Schooling Assessment

Video Consent and Release Form
Name of Child referred to in the Video interview
First Last
Parent or legal guardian of the above-named minor child.
First Last
The below-signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child.
Email*
Consent is given to Dr. John Flett for the purpose of education
This consent includes, but is not limited to: ( select where applicable)*
- Deselect All
- (a) Permission to interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice
- (b) Permission to use my name.
- (c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.
This consent is given in perpetuity and does not require prior approval by me.
Date*
DD slash MM slash YYYY
Signature of Parent or Legal Guardian:*
Should you need clarification regarding the consent or any other concern, please do not hesitate to contact me before signing the consent.

Video Consent and Release Form