"*" indicates required fields

Name of Volunteer*
Name of Caseworker*
I, hereby consent to Big Brothers Big Sisters of Canada (National Office) and its associated member Big Brothers Big Sisters agencies of Big Brothers Big Sisters of Waterloo Region the use of any photographs, audio and/or video recordings of myself as taken or produced by media personnel and/or National Office or Local Agency staff at recreational events or match outings, or otherwise authorized by the National President & CEO, local agency President/Executive Director/CEO or Board of Directors, and that this media may be used by Local Agency and/or by the National Office for purposes of promotional material including brochures, posters, newsletters, media information, advertisements, audio-visual productions and digital media, (such as the local agency websites and social media). Photographs or video productions may also be shared with community and school partners for program promotion. I further waive any claim which I may have against Big Brothers Big Sisters of Canada and its associated member Big Brothers Big Sisters agencies arising from the use of such photographs, audio and/or video recordings of myself, as aforesaid. This consent and waiver shall remain in effect unless otherwise revoked.
I hereby give consent. Please check no if you do NOT want your picture to be used:*
Note: It is your 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.*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.
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