“Lesson Learnt”

Consent Form

We are writing to ask for permission to use footage containing you as a

part of our A Level Media course at Chelmer Valley High School. The
footage will be used as part of our media coursework and only that. It will
be placed publicly on ‘you tube’ and it will be viewed by us, our teachers
and our examiners.

The filming will take place in January 2010; the actual dates will be shown
on an attached letter. We can guarantee that no information will be
issued that could identify you personally. It is your decision whether you
wished to be credited or not.

In the case of a person under 18 years of age, their parent/guardian

should also sign this consent form where indicated below.

I………………………………………………………………… (Full name)

Address………………………………………………………………………………………
…………………………………………………………………………………
I understand and agree that the footage taken of me, my performance
and/or my property together may be used, published, reproduced,
adapted, recorded, modified and complied by KingsFord Production for the
purposes of the “lesson learnt” short film. I understand that by giving
consent, the film that I will appear in will be shown publicly on ‘you tube’.

Signature………………………………………………………………
Print Name…………………………………………………………..
D.O.B…………………….. Age………………….
Date………………………

Name and address of

School/College………………………………………………………………………………
………….
…………………………………………………………………………………………………
……………………………………………………………....

If your are under 18

I…………………………………………………………………….(name) the
parent/guardian of………………………………………………………(name of
child)