Community Health Initiative Filming Consent Form
Please complete this form to provide your consent for filming as part of our community health initiative.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to the Initiative
*
Please Select
Participant
Parent/Guardian
Community Member
Volunteer/Staff
Other
Consent Details: I hereby give permission for myself or my child (if under 18) to be filmed, photographed, or recorded as part of the Community Health Initiative. I understand that these materials may be used for educational, promotional, or informational purposes by the organization. I acknowledge that participation is voluntary and that I may withdraw consent at any time.
*
I agree and give my consent
I do not agree
Signature (Please sign below to confirm your consent)
*
Date of Consent
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Comments or Questions (optional)
Submit Consent
Submit Consent
Should be Empty: