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Image Consent Form

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Content last updated 25/08/2020

Image Consent Form

  • MM slash DD slash YYYY
    Please advise the date you attended this event or activity.

  • I agree to the use of my image or if applicable, the image of my child/ren, name, words or story for the purpose of either media, social media or promotional marketing activities for Gold Coast Primary Health Network (GCPHN).

    I understand that the image, name, words or story may be used by GCPHN for promotion and publicity purposes and may appear in a wide range of materials, including but not limited to media stories, newsletters, official publications, posters, presentations, advertising, social media and the GCPHN website.

    I understand that I or my children may be identified if images are used for any such purposes.

    I acknowledge that GCPHN owns, and shall own all rights, title and interest (including copyright) which may arise from any media footage which I/we have participated in. I further acknowledge that Gold Coast Primary Health Network is not obliged to use any media footage in which I/we have participated in.

    I understand that I/we will receive no monies for any involvement in media footage used by GCPHN.

    I understand the image, name, words or story will be held on file at Gold Coast Primary Health Network for a minimum period of 7 years after which it may be destroyed.

    I also acknowledge that while GCPHN will try to protect my/our interests, once I /we participate, GCPHN has no control over what gets published or what goes to air or how the media or public use the information that I give them.

    I give permission to GCPHN (and any person authorised by them) to copy or reproduce such material as GCPHN may determine, without acknowledgement of myself/or children and without entitlement to any remuneration or compensation now or in the future.

  • MM slash DD slash YYYY

In complying with the relevant legislation and the Australian Privacy Principles 2014, Gold Coast Primary Health Network (GCPHN) provides the following advice about how GCPHN handles, holds and permits access and correction of personal information in accordance with the Australian Privacy Principles including how to complain about a breach in privacy and request corrections to personal information. GCPHN collects personal information for the purpose of assisting its activities and functions in the primary health care sector. If your contact details are collected they may be used to forward information and notifications from GCPHN. In some circumstances we may provide information to our funding agency (Department of Health) or to service providers that enter into legal contracts with us which are bound by confidentiality. There is no legal
requirement for you to provide your personal information, however if you choose not to disclose your personal information this may exclude you from our services and programs. We do not routinely disclose information overseas. For further information on how we manage your personal information see our privacy policy.