Consent For Photography

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HSO208

Photography, Video and Audio Consent

Name of organisation:
Address:

Telephone:

Permission has been granted for Deakin University Occupational Therapy students to take photos, as agreed by
the workplace. Consent is also given to the use of the photographs for the following specified purpose(s).

The photographs will be kept only for the educational purposes listed and not published or used for other
purposes.

o Workplace description and assessment as part of the Occupational Therapy program, assignment and
discussion
o Educational purposes
o Or specify:

Signature: Date:

Position: _________________________________________________________

Students Name:.. OT Deakin University

_________________________________________________________________________________________________

Privacy Statement
Your name and contact details are collected on this form in order to have a record of your consent to the taking and use of photographs and
to be able to contact you about the photographs if necessary. You have a right to gain access to your personal information held by the
nominated centre.

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