Media Consent Form-Child

By completing this form I, the (parent/guardian) of the child named below, give consent and agree that WILLEN HOSPICE, its employees, or agents have the right to take images (photographs), video recordings and/or audio of the child named below and to use these in any and all media, now or hereafter known, and exclusively for the purpose of promoting WILLEN HOSPICE.

I further consent that my child’s name and identity may be revealed therein or by descriptive text of commentary.

I do hereby release WILLEN HOSPICE, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies.  I waive any rights, claims, or interest I may have to control the use of my child’s identity or likeness in whatever media used.  I understand that there will be no financial or other remuneration for recording my child, either for initial or subsequent transmission or playback.

I also understand that WILLEN HOSPICE is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result.

Your Name(Required)
Child's Name(Required)
In a typical year...
our cost, per minute
phone calls to patients at home
fabulous volunteers
patients cared for at home
home visits
patients at the hospice
of cups of tea
counselling sessions
We can only provide the care we do thanks to the incredible generosity of our community, through their continued volunteering, fundraising and donations throughout the year. Your donation will enable us to continue providing care and support to those facing a life-limiting diagnosis, and to support their loved ones.