CONSENT FORM FOR MEDIA

The Pambansang Koalisyon ng Kababaihan sa Kanayunan (PKKK) is a national coalition that

promotes gender equality and equal rights and opportunities for girls and young women, with
focus on the elimination of gender-based violence (GBV) and the economic empowerment of
girls and young women. 

This consent form should be completed by children, young people or adult who are involved in
interviews, photography or filming organized by PKKK. Where participants are under 18 years of
age or over 18 but do not have the capacity to provide consent, their parent, guardian or other
legal representative should give consent by signing this form.

Subject of Contribution:
PKKK Youth Advocates Assembly 2020
Date of Contribution : November 28,, 2020
Venue: Online via zoom
To be completed by the contributor or subject of photography/video/statement
1. I agree to participate the above interview/filming/photography
2. I agree that some or all of the information, images, video footage, interviews and other
contribution I make appear maybe used for any of the following purposes.
● To publicise and promote PKKK
● For marketing of the organization
● To promote PKKK advocacy, educational and/or media work
3. I agree that my contribution may be used in these ways by PKKK and I understand that
PKKK may share its contribution with networks and allies with the same advocacy
4. I understand that any information, image, photography or video footage made may be
used in any forms of statement including TV/radio, electronic media includes social
media and internet, and production of reading materials

5. I understand that any images, video footage photography is uploaded to social media or
other website, then PKKK has no control over the copying or distribution of such material
by other internet
6. I also understand that my consent or participation in the above
interview/filming/photography does not affect my involvement in PKKK programs or
project

Name :______________________________________________________
Address/community Name:______________________________________
Signature :__________________________ Date : ___________________________

Parent, Guardian, Legal Representative a

I confirmed that I am the contributor’s parent/guardian/legal representative and agree to the

above in behalf of the contributor

Name: ______________________________________________________________
Address/Community Name :_____________________________________________
Relationship to Contributor: ______________________________________________
Signature______________________________________ Date: __________________