Parent Consent Form- “Media and Information Literacy-Documentary Making”
Name of Participant ………………………………Date of Birth ………………………...……………….……
Parent/ Guardian ………………………………………………………………………………………......
Address: ……………………………………………………………………………………...…………………….
………………………………………………………...……........................… Postcode ………………………
Tel (day): …………………………….................. Tel (evening): ……………………….................…………
Mobile: …………………………………………………….. e-mail: ……………………………........................
Do your suffer from any medical conditions/allergies that the program should be aware of (including any
current medication) .........................................................................................................
………...…………………….………………………………………………………………………………..……
…...……………………………………………………………………..……………………………..…………..
Please provide details of medication that must be administered: ………………………………………….
……………………………………………………………………………………………………………………..
…………………………………………..……………………………..……………………………..……………
Emergency contact details: (If different from above)
Name: ……………………………………………………………… Telephone no: ……………..…………
Relationship to the participant:……………………………………………………………………………….
CONSENT (please read carefully)
a) I agree that I, _____________ will be taking part in making a
documentary.
b) I confirm to the best of my knowledge that I do not suffer from any
medical condition other than those listed above.
c) I am willing to travel by any form of public transport, minibus or
motor vehicle.
d) I understand that Media and Information Literacy subject, documentary making include
photography and film component in which I will be both photographed and a photographer. I
understand that these images will be part of the documentary process.
e) I hereby acknowledge that Lemery National High School, its management, personnel,
employees and agent may not be held responsible for any untoward incident which is beyond
their control.
Signed ………………………………….....................… (Parent/ Guardian) Date: ……………………………