Name of Student *

First Name

Last Name

Parent/Guardian Name (if student is under 18):

First Name

Last Name

Phone *

(###)

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Consent for Photography, Video, and Media Use *

I hereby grant permission to the NOW Program partners listed below to photograph, video record, and/or interview me (or my child if under 18). I understand that these photos, videos, or recordings may be used in print, online, and social media publications to promote programs and services for newcomers. This consent includes the following organizations and their partners in London and St. Thomas-Elgin: - School Boards: Thames Valley District School Board (TVDSB) and London Catholic District School Board (LCDSB) - Settlement Agencies: London Cross Cultural Learner Centre (CCLC), LUSO Community Services, South London Neighbourhood Resource Centre, and WCA St. Thomas-Elgin I understand that: - The materials may be used without restriction for educational, promotional, or informational purposes. - I will not receive payment or compensation for the use of these images/videos. - My participation is voluntary, and I may withdraw consent at any time by contacting one of the agencies above.

Yes, I consent to the use of my/my child’s photo, video, or interview by the partners listed above.

No, I do not consent to the use of my/my child’s photo, video, or interview.

Date

MM

DD

YYYY