Professional Documents
Culture Documents
In giving Suffolk GP Federation permission to use your material (photograph/case study) you
are supporting the vital work the organisation does. If you would like a copy of anything your
material is used in please request one and we will send it to you. Thank you.
NOTE: Where a parent/carer is giving consent on behalf of a child or young person the
name of the child or young person is inserted in the box below and the name of the
parent/carer inserted in the agreements section.
Name of person
giving consent:
Age
If the person giving YES ☐ NO ☐
consent is an adult
(over 18 in England, If NO please explain why:
Northern Ireland and
wales and over 16 in
Scotland) are they
able to consent in
their own right:
Age – if under 18:
Address:
Telephone:
Type of material:
I give Suffolk GP Federation the right to use the material named above.
I understand that my material will become part of Suffolk GP Federation’s library and/or
media store and may be used in/on (description of use to be inserted):
I understand that my material will be stored and used for up to three years from today’s date,
unless otherwise specified below.
Name of parent/guardian:
Signature of parent/guardian:
Date:
Date: