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LAAS | Lifestyle Assistance & Accommodation Service

QF417 Media Consent Form

Consent is given for Lifestyle Assistance and Accommodation Service to create, reproduce, exhibit, publish, or distribute any likeness of myself with the understanding of the following points.

Such material may be used for the promotion of Lifestyle Assistance and Accommodation Service and its services through the media, including brochures or newsletters and other organisational documents to assist people utilise such services. Use of the material may include, but is not limited to, videotapes, DVD's, films, photographs, displays, brochures, web sites, multi-media programs, or any other type of promotional material.

In granting this permission, I acknowledge that there shall be no claim by my behalf for any monetary compensation in the use of such material either now or in the future. Such permissions will remain valid until notification to the contrary is received in writing by Lifestyle Assistance and Accommodation Service.

Such permission can be revoked at any time with the understanding that pre-existing material may continue to be used by Lifestyle Assistance and Accommodation Service but no further new material will be used from the 'revoked date'.

Customer/Client to complete

Part 1 – I specify the following limitations of consent:

Review of Consent
Consent should be reviewed on a regular basis as agreed with the Customer/Client. If there are any changes to this document a new form should be completed to reflect the current wishes of the Customer/Client (or, if the Customer/Client is incapable of giving consent, the review may be made by Enhanced Lifestyles and Lifestyle Assistance and Accommodation Service and/or the Customer/Client Representative should they feel it is necessary and in the best interest of the Customer/Client to do so).

Clients Name:

Date:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

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Timestamp

Audit

February 19, 2021 7:55 pm ACDT

QF417 Media Consent Form Uploaded by Meg Walker - admin@www.laas.com.au IP 125.168.64.82

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