[short film] CONSENT FORM Title of Project: Dark Earth Name of Researcher: Cameron Hay Please intial all boxes 4. | confirm that | have read and understand the information sheet dated 30/04/2019 (version 1) for the above study. | have had the opportunity to consider the information, ask questions and have had these answered satisfactorily, 2. | understand that my participation is voluntary and that | am free to withdraw at any time without alving any reason, without my medical care or legal rights being affected 3. | understand that relevant sections of my medical notes and data collected during the study, may be looked at by individuals from Hay films , from regulatory authorities or from the NHS Trust, where itis relevant to my taking part in this research. | give permission for these individuals to have access to my records. 4. Lagree to my GP being informed of my participation in the study. 5. | agree to take part in the above study. Cameron Ha) 30/04,19 Name of Participant Date Signature Name of Person Date Signature taking consent Consent form date of issue: [30/04.19] Consent form version number: [ONE 1 Page 1 of 1