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:
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 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.
Agreements
This permission form has been
explained to me by (a member
of Suffolk GP Federation staff):
Signature of person giving
consent:
Name of parent/guardian:
Signature of parent/guardian:
Date: