Media Consent Form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Sharing of Information and Media Communications

From time to time we may have media attend LYS Inc. for promotional or other purposes or may be asked for images or quotes. By attending LYS Inc., you consent to any media images, quotes or otherwise being included in any promotion or documentary of LYS Inc.. If you do not wish to be included in any promotion or media, please advise LYS Inc. in writing so it can be included on file. • Information provided to LYS Inc. may also be shared with organisations for the purposes of follow up or case management or otherwise where a government authority may compel us to provide it. Please see our Privacy Policy for further information on what information is collected, used and stored.

Video Recording and Safety

You understand that we have video cameras around our premises for the safety and security of both LYS Inc. and all members of LYS Inc. We have the right to record and store your image and all video footage (‘Recordings’) for a reasonable period in compliance with relevant regulations. We will only use and share these Recordings where is it necessary to protect any of our employees, volunteers, contractors or other members or attendees of LYS Inc. We may also be compelled to produce these Recordings by relevant authorities if requested. By signing this consent and attending LYS Inc., you agree to permit us to record and store any Recording of you whilst on our premises.

I consent to future contact for evaluation purposes *

Yes

No

Consent *

(if under 18 years a guardian needs to consent for you)

I consent to participating in any activities involved in LYS Inc. programs.

I give consent to being transported to and from LYS Inc. programs

Parent/Guardian Name

First Name

Last Name

Marketing

I do not wish to receive marketing updates via email or text.