َ ‫ﺗَو ِﺛﯾﻖْ ﻣواﻓَــﻘَـﺔ‬
‫ﺷﻔَـــ ِﮭﯾـَـﺔ‬
For promoting the mission of WFP and BFD , and without anticipating any
compensation perpetuity.
I hereby give WFP and BFD, their representatives, their affiliated entities
and agents or partners, the absolute right and permission to use my name
or my child's name and my photo or my child's photo (Either photographs
or video and electronic videos) and /or any statements issued by me
during personal interview and personal quotations, to be published in their
printed materials , announcements or other global activities ( including
internet)
This consent includes without limitation the follow:
(i) Authorize for interviews, record my voice , taking photograps,
video, …. etc. For the purpose of making video versions of
myself or my child/children and/or recording our voices,
(collectively refer herinafter as the “Materials”).
(ii) Authorize using my name and /or my child/children name.
(iii) Authorize using my qoutotion or license or sub-license for my
quotation of the interview(s) (or excerpts thereof), or recording
our voices, photographs, video records, transcribing partially
and fully, in their publications, newspapers, magazines and
other electronic media (including Internet) and through
modern theatrical media and / or correspondence, which are
all used in educational and awareness campaigns carried out
by WFP and BFD in order to advertise their products and / or
collect donations.
(iv) Edit, duplicate and use, or license others to edit, duplicate and
use what mentioned above (and my name), separately or in
conjunction with other works, content or materials, worldwide
and in any media or manner, for the purpose of raising
awareness of and funds for the World Food Programme and
BFD.
I understand that there will be no financial or other remuneration for any
such use of my name, picture, image, appearance or performances and
hereby release WFP and BFD, its licensees and free them from all liability
and claims of any nature whatsoever resulting from or connected with the
use thereof.
Data of the consenting person (If the age is more than 18 years)
Name/
Signature/
Date / Adress /
Data of the consenting person (If the age is less than 18 years)
Child's name/
Child's age /
Name of legal guardian or person in charge/
Signature of legal guardian or person in charge/
Date / Adress/
By signing this consent form, the legal guardian of the minor child or child’s
person in charge agrees and authorizes the foregoing on behalf of the
child
The name of BFD focal point that presents in site /
Signature /
DOCUMENTATION OF VERBAL CONSENT
ً
�� ‫�ﻌﺰ�ﺰا ﳌهﻤﺔ ﺑﺮﻧﺎﻣﺞ اﻷﻏﺬﻳﺔ اﻟﻌﺎﳌﻲ وﻣﺆﺳﺴﺔ ﺑﻨﺎء ﻟﻠﺘﻨﻤﻴﺔ ودون ﺗﻮﻗﻊ ﻷي ﻣﻘﺎﺑﻞ أو �ﻌﻮ�ﺾ‬
‫ أﻣﻨﺢ ﺑﺮﻧﺎﻣﺞ اﻷﻏﺬﻳﺔ اﻟﻌﺎﳌﻲ وﻣﺆﺳﺴﺔ ﺑﻨﺎء ﻟﻠﺘﻨﻤﻴﺔ وا�جهﺎت اﻟﺘﺎ�ﻌﺔ‬،‫اﻟﻮﻗﺖ ا�حﺎ�� أو �� اﳌﺴﺘﻘﺒﻞ‬
‫ﻟهﺎ ووﻛﻼ��ﺎ اوﺷﺮ�ﺎ��ﺎ ﻣﻮ اﻓﻘ�ي ﻋ�� اﺳﺘﺨﺪام اﺳ�ي أو اﺳﻢ ﻃﻔ�� أو ﺻﻮر�ﻲ أو ﺻﻮرة ﻃﻔ�� )ﺳﻮاء‬
‫أو أي ﺗﺼﺮ�ﺤﺎت ﺧﻼل اﳌﻘﺎﺑﻼت‬/‫أو اﳌﻘﺎﻃﻊ اﻹﻟﻜ��وﻧﻴﺔ( و‬/‫اﻟﺼﻮراﻟﻔﻮﺗﻮﻏﺮ اﻓﻴﺔ أو ﻣﻘﺎﻃﻊ اﻟﻔﻴﺪﻳﻮ و‬
‫)واﻻﻗﺘﺒﺎس ﻣﻦ ﺗﻠﻚ اﻟﺘﺼﺮ�ﺤﺎت( ﺗﺼﺪرﻋ�ي أوﻋﻦ ﻃﻔ�� �� ﻣﻄﺒﻮﻋﺎ��ﺎ أو إﻋﻼﻧﺎ��ﺎ أواﻟنﺸﺎﻃﺎت‬
. (‫اﻟﻌﺎﳌﻴﺔ اﻷﺧﺮى )ﺑﻤﺎ �� ذﻟﻚ اﻹﻧ��ﻧﺖ‬
:‫و�ﺸﻤﻞ هﺬﻩ اﳌﻮ اﻓﻘﺔ ﻋ�� ﺳبﻴﻞ اﳌﺜﺎل ﻻ ا�حﺼﺮ‬
‫( اﻟﺘﺼﺮ�ﺢ �ﻌﻘﺪ ﻣﻘﺎﺑﻼت واﻟت�جﻴﻞ واﻟﺘﺼﻮ�ﺮاﻟﻔﻮﺗﻮﻏﺮا�� واﻟﻔﻴﺪﻳﻮ وﻏ��ذﻟﻚ �ﻐﺮض‬i)
‫ )اﳌﺸﺎراﻟ��ﺎ‬،‫أو ��جﻴﻞ اﺻﻮاﺗﻨﺎ‬/‫ أﻃﻔﺎ�� و‬/ ��‫إﻋﺪاد إﺻﺪارات ﻣﻦ اﻟﻔﻴﺪﻳﻮ �� أو ﻟﻄﻔ‬
"( ‫�ﺸ�ﻞ ﺟﻤﺎ�� ﺑـ "اﳌﻮاد‬
. ��‫ أﻃﻔﺎ‬/ ��‫أو اﺳﻢ ﻃﻔ‬/‫( اﻟﺘﺼﺮ�ﺢ ﺑﺈﺳﺘﺨﺪام اﺳ�ي و‬ii)
‫ اﳌﻘﺎﺑﻼت )أو‬/ ‫( اﻟﺘﺼﺮ�ﺢ ﺑﺎﻻﻗﺘﺒﺎس أو ﺗﺮﺧﻴﺺ أو إﻋﺎدة ﺗﺮﺧﻴﺺ اﻻﻗﺘﺒﺎس ﻣﻦ اﳌﻘﺎﺑﻠﺔ‬iii)
‫ أو اﻟت�جﻴﻞ أو اﻟﺘﺼﻮ�ﺮاﻟﻔﻮﺗﻮﻏﺮا�� أو اﻟﻔﻴﺪﻳﻮ أو اﻟن�خ أو ﺗﺼﻮ�ﺮﻧﺎ‬،(‫ﻣﻘﺘﻄﻔﺎت ﻣ��ﺎ‬
‫ �� ﻣﻄﺒﻮﻋﺎ��ﺎ واﻟ�حﻒ وا�جﻼت وﻏ��هﺎ‬،��‫أو ��جﻴﻞ أﺻﻮاﺗﻨﺎ �ﺸ�ﻞ ﺟﺰئﻲ أو ﻛ‬/‫و‬
��‫ﻣﻦ وﺳﺎﺋﻞ اﻷﻋﻼم اﻹﻟﻜ��وﻧﻴﺔ )ﺑﻤﺎ �� ذﻟﻚ اﻹﻧ��ﻧﺖ( وﻋ��وﺳﺎﺋﻞ اﻹﻋﻼم اﳌﺴﺮ‬
‫أو اﳌﺮاﺳﻼت اﻟ�ي �ﺴﺘﺨﺪم ﺟﻤﻴﻌﺎ �� ﺣﻤﻼت اﻟﺘﺜﻘﻴﻒ واﻟﺘﻮﻋﻴﺔ اﻟ�ي‬/‫اﳌﺴﺘﺤﺪﺛﺔ و‬
‫أو‬/‫ﺗﻘﻮم ��ﺎ ﺑﺮﻧﺎﻣﺞ اﻷﻏﺬﻳﺔ اﻟﻌﺎﳌﻲ و ﻣﺆﺳﺴﺔ ﺑﻨﺎء ﻟﻠﺘﻨﻤﻴﺔ ﻣﻦ أﺟﻞ اﻟﺪﻋﺎﻳﺔ ﳌﻨﺘﺠﺎ��ﺎ و‬
.‫ﺟﻤﻊ اﻟﺘ��ﻋﺎت‬
‫ أو اﻟ��آﺧﻴﺺ ﻵﺧﺮ�ﻦ ﺑﺘﺤﺮ�ﺮو��خ واﺳﺘﺨﺪام ﻣﺎ ﺗﻘﺪم‬،‫( وﺗﺤﺮ�ﺮو��خ واﺳﺘﺨﺪام‬iv)
‫ ﻋ�� ﻧﻄﺎق‬،‫ ﺑﺼﻮرة ﻣﻨﻔﺼﻠﺔ أو ﻣﻘ��ﻧﺎ ﺑﺄﻋﻤﺎل أو ﻣﺤﺘﻮ�ﺎت أو ﻣﻮاد أﺧﺮى‬،(‫)واﺳ�ي‬
‫ ﻟﻐﺮض ﻟﺮﻓﻊ اﻟﻮ�� ﺑ��ﻧﺎﻣﺞ اﻷﻏﺬﻳﺔ اﻟﻌﺎﳌﻲ وﻣﺆﺳﺴﺔ ﺑﻨﺎء‬،‫اﻟﻌﺎﻟﻢ و�ﺄي وﺳﻴﻠﺔ أو ﻃﺮ�ﻘﺔ‬
.‫ﻟﻠﺘﻨﻤﻴﺔ‬
،‫ أو ﻣﻈهﺮي‬،‫ أو ﺻﻮر�ﻲ‬،‫وأدرك أﻧﮫ ﻟﻦ ﺗﻜﻮن هﻨﺎك أﻳﺔ ﻣ�ﺎﻓﺄة ﻣﺎﻟﻴﺔ أو أﻏ��هﺎ ﻋﻦ أي اﺳﺘﺨﺪام ﻻﺳ�ي‬
،‫ وﻣﻦ ﻳﺮآﺧﺺ ﻟهﻢ وﻣﻦ ﻳ�ﻠﻔهﻢ‬، ‫ و�ﺬﻟﻚ أﻋﻔﻲ ﺑﺮﻧﺎﻣﺞ اﻷﻏﺬﻳﺔ اﻟﻌﺎﳌﻲ وﻣﺆﺳﺴﺔ ﺑﻨﺎء ﻟﻠﺘﻨﻤﻴﺔ‬،‫أو أدائﻲ‬
.‫ واﻟ�ي ﻗﺪ ﺗن��ئ ﻋﻦ اﺳﺘﺨﺪام ﻣﺎ ﺗﻘﺪم أو �ﻌﻠﻖ ﺑﮫ‬،‫ أﻳﺎ �ﺎﻧﺖ ﻃﺒﻴﻌ��ﺎ‬،‫ﻣﻦ ﺟﻤﻴﻊ اﳌﺴﺆوﻟﻴﺎت واﳌﻄﺎﻟﺒﺎت‬
(‫ ﻋﺎم‬18 ‫ﺑﻴﺎﻧﺎت ﺻﺎﺣﺐ اﳌﻮ اﻓﻘﺔ )إذا �ﺎن اﻟﺴﻦ أﻛ�� ﻣﻦ‬
/‫اﻹﺳـﻢ‬
/‫اﻟﺘﻮﻗ ـﻴــﻊ‬
/‫اﻟﻌﻨ ــﻮان‬ /‫اﻟﺘﺎر�ــﺦ‬
(‫ ﻋﺎم‬18 ‫ﺑﻴﺎﻧﺎت ﺻﺎﺣﺐ اﳌﻮ اﻓﻘﺔ )إذا �ﺎن اﻟﺴﻦ أﻗﻞ ﻣﻦ‬
/‫إﺳــﻢ اﻟﻄﻔﻞ‬
/‫ﺳﻦ اﻟﻄﻔﻞ‬
/��‫إﺳﻢ و�� اﻷﻣﺮأواﻟﻮ��ي اﻟﺸﺮ‬
/��‫ﺗﻮﻗﻴﻊ و�� اﻷﻣﺮأواﻟﻮ��ي اﻟﺸﺮ‬
/‫اﻟﻌﻨــﻮان‬ /‫اﻟﺘﺎر�ﺦ‬
‫ ﻳﻮ اﻓﻖ ويﺴﻤﺢ و�� اﻷﻣﺮأو اﻟﻮ��ي اﻟﺸﺮ�� ﻟﻠﻄﻔﻞ اﻟﻘﺎﺻﺮﺑﻤﺎ ﺳﺒﻖ ﻧﻴﺎﺑﺔ ﻋﻦ اﻟﻄﻔﻞ‬،‫ﺑﻤﻮﺟﺐ اﻟﺘﻮﻗﻴﻊ هﻨﺎ‬
/‫إﺳﻢ ﻣﺴﺆول ﻣﺆﺳﺴﺔ ﺑﻨﺎء ﻟﻠﺘﻨﻤﻴﺔ اﳌﺘﻮاﺟﺪ‬
/‫اﻟﺘﻮﻗﻴ ــﻊ‬
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