"*" indicates required fields

Name of Child/Youth*
Name of Parent/Guardian*
Name of Caseworker*
MM slash DD slash YYYY
Any photographs or video productions taken of children or youth by agency staff at recreational events or match outings, or otherwise authorized by the Chief Executive Officer or Board of Directors, may be used by the agency for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and web pages, such as the Agency website and social media. Photographs or video productions may also be shared with community and school partners for program promotion.
I hereby give consent
If you do not want your child's picture used or if you have a safety concern, please check no. I do not give consent.

Note: It is the parent/guardian's responsibility to notify the office if the status of this consent changes.
I have read, understand and completed the Media Consent Form. By clicking YES I hereby confirm that the information provided is accurate, correct and complete to the best of my knowledge. I authorize Big Brothers Big Sisters of Waterloo Region to use the information I provided within their agency.*
This field is for validation purposes and should be left unchanged.
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