Media Consent form Client name(Required)Overview Mansfield Autism is committed to protecting the privacy of personal information. Our privacy policy guides how we do this; you can find it on our website here: https://autismmansfield.org.au/privacy-policy/ Personal information can include things like name, date of birth, NDIS number, medical and assessment reports, but also photographs, films and any other recordings. This form asks you to consent to us sharing information with people or organisations involved in the care of your child, and for taking photos or film recordings during service delivery. Consent is optional and we will respect your decision. You can also withdraw consent at any time by writing to us.Consent to share information In some cases we may work with other agencies or people as part of a client’s care team to coordinate the best support for you and your family. For this reason we sometimes need to share assessments and reports with care team members such as support coordinators, paediatricians or allied health therapists.I consent to Mansfield Autism sharing information about me/my child with members of the care team.(Required) YES NO Limitations to my consent (if any)Media Consent Our staff may photograph or film clients during service delivery e.g. to celebrate and share achievements, to demonstrate skillbuilding or to display at the school or on campus (Internal purposes). We also sometimes use images in our promotional materialsuch as our annual report, newsletter, social media or website. Client names are never published.I consent to images or recordings of me/my child to be used for marketing/promotional purposes(Required) YES NO I consent to images or recordings of me/my child to be used for internal purposes(Required) YES NO Media ConsiderationsPlease tell us any social or cultural considerations we should be aware of when sharing images or recordings:Acknowledgement(Required) I understand I can withdraw or change my consent at any time by contacting Mansfield Autism in writing. Parent / Guardian name(Required)Date(Required) DD slash MM slash YYYY Relationship to client(Required)Signature(Required)
