MEDIA CONSENT FORM

(For Ages 17 Years and Younger)

PURPOSE

The information on this form is collected in order to obtain your consent to the
publication of your child’s submission content and information, subject to the limitations
set out in the section titled “LIMITING PUBLICATION OF CHILD’S INFORMATION”.
The information collected on this form will be used for the purpose for which you have
provided, and we will not disclose it without your consent, unless authorized or required
by law.

CHILD’S INFORMATION

Name: ______________________________________________ Age: ____________

School, City/Town, Province: ______________________________________________

School year level: _______________________________________________________

PARENT/GUARDIAN INFORMATION

Name: ____________________________________ Relation to child: _____________

Address: ______________________________________________________________

City/Town, Province, Postal Code: __________________________________________

Email: ________________________________________________________________

CONSENT TO USE CHILD’S SUBMISSION CONTENT

On behalf of ______________________________________________________(name
of child)

I _________________________________________________________________
(name of parent or guardian)

give permission to Healthy Debate (HD), the Young Canadians Roundtable on Health
(YCRH) and The Sandbox Project (TSP), for the purpose of releasing, sharing and/or
publicizing the submission content of my child. I understand that the nature of such
submission may include singly or in combination: art, image, photograph, video, voice or
writing.

LIMITING PUBLICATION OF CHILD’S INFORMATION

If your child’s submission content is chosen for publication, you may allow or restrict use
of your child’s personal information. To EXCLUDE any of the items below, write NO in
the space beside it, orTo INCLUDE any of the items below, write YES in the space
beside it:

Name of child: ____________________________________________________

Picture of the child: ________________________________________________

Name of child’s School, Town/City, Province: ____________________________

School year level of Child: __________________________________________

Name of your home Town/City, Province: _______________________________

IMPORTANT ACKNOWLEDGEMENT

I understand and acknowledge that the choice to use or not use any child’s submission
rests solely with HD, YCRH and TSP, and that I will not receive any compensation for
the right to use my child’s material.

I understand and acknowledge that if my child’s submission content is chosen for

publication, it may appear: on the internet; in print, electronic, or video-media; and may
enable readers to identify my child.

I understand and acknowledge that if my child’s personal information (name, school or

image), photograph, video, comments and/or voice recording is published on the
internet, it will be accessible to millions of users across the world, including media
outlets, that it will be indexed by search engines and that it may be copied and used by
any web user, that his/her information can be searched for using an identifier such as
the school name, and that my child’s information can be copied and used by any other
person using the internet.

I also understand and acknowledge that, once my child’s personal information or

comments has been published on the internet, neither HD, YCRH or TSP have any
control over its subsequent use and disclosure, and that I will not hold them responsible
for any harm that may arise from such unauthorized reproduction.

______________________________________________
(name of parent or guardian)

________________________________________ Date: _______________________

(signature of parent or guardian)

Please note, if you wish to withdraw your consent and child’s submission at a future
date, contact: ycrh@sandboxproject.ca