Image and Story Consent Form - Playlist for Life

Thank you for your interest in taking part in a media project for Playlist for Life. Whether you are taking part in a film, an audio recording, a photography session, or sharing your story with us to use as a case study, we want the experience to be positive for you. It is very important that you are comfortable with what we are doing and how we plan to use your contribution. This form explains how we will use your contribution and asks you to give us permission to record your contribution you and share that publicly.

With your permission, we will keep in touch with you after the recording has been made to keep you updated about its use and ensure you continue to be happy with our use of it.

What is Playlist for Life?

Playlist for Life is a UK charity that helps people with dementia find and use music that can make them feel better. We train health and care professionals in using music, provide a network of Community Help Points where people can find a helping hand to get them started using music, and we raise awareness of the power of music.

Why do we want to share your story?

We recognise that the best people to help others understand the experience of living with dementia, caring for someone with dementia, or using music are people who have experienced that. So when we train people or raise awareness of the power of playlists we like to use real people’s stories, ideally told by those people themselves. We record films, audio programmes, photo-stories and other types of media to share those real-life stories in the most immediate way. Your contribution will be part of that.

How will we use your contribution?

We will record an interview with you and/or take your photograph and will edit your contribution into a short film, audio recording or photo-story. We will make that available publicly on our website, on our social media channels, or will share it with journalists or partners. If your circumstances change at a later date and you decide you no longer wish us to use your contribution to our film, please tell us and we will stop using it.

Agreement

Name of contributor*

Organisation

Address*

Street address line 1 Street address line 2 Town / city Postcode

Phone number*

Email address*

Name of Playlist for Life staff member

I grant Playlist for Life the right to use the whole or part of my contribution in its training and awareness raising activities.
I agree that Playlist for Life may edit, adapt, or translate my contributions.
I assign to Playlist for Life the copyright and all other rights in my contributions.
I waive any “moral rights” as defined by the Copyright Designs and Patents Act 1998 that may exist in my contribution.
I agree that Playlist for Life may use my contribution in all media, including online media.
I agree that Playlist for Life may contact me to keep me updated about its use of my contribution.
I have read and understood the terms of the Privacy Notice for Media Contributors.

If you are unsure of the meaning of any of the conditions set out above, please ask a Playlist for Life staff member who will be able to explain them to you.

Are you completing this form for yourself or on behalf of someone else*

I am completing it for myself

I am completing it on behalf of someone who lacks capacity or is under 16 years of age.

What is your relationship to the person sharing their story?*

If the person sharing their story is under 16 years of age please enter their date of birth*

Confirmation of acceptance*

Please enter your name in the box below to confirm that you understand and agree to the statements above. If you lack capacity or are under 16 then your guardian or parent should tick the box above and complete the additional questions that appear.

Name

This field is for validation purposes and should be left unchanged.

We take your privacy very seriously and will only ever use your information for the purposes you have agreed to. For more details on how we protect your information please see our Privacy Policy.