Consent Form

Women’s Health– It’s time to stop living with it

In order to allow us to share your story as part of our campaigning, we need your consent which you can give us by completing the form below.

Please share either your written story or upload a short video at the bottom of the page

    1. I have participated as indicated on the above Production Title.
    2. In consideration of my appearance in the Women’s Health Initiative, and without any further consideration from you, I hereby grant permission to you to utilise my appearance in connection with the Women’s Health Initiative in any manner, including media and all rights of every kind and character whatsoever in perpetuity.
    3. I consent to my performance, appearance, name and voice in connection with the Women’s Health Initiative and confirm that Women in Data® Limited may edit at its discretion and include it with the performance of others and with sound effects, special effects and music; to incorporate the same into the Women’s Health Initiative or any other Production title or other programme or not; to use and to license others to use such recordings and photographs in any manner or media whatsoever, including without limitation unrestricted use for purposes of publicity; and to use my name, likeness, voice, biographic, or other information concerning me in connection with the Production Title in any video, picture, photographs, and for any other purpose.
    4. I further acknowledge that Women in Data® Limited owns all rights and I agree that my participation in the Women’s Health Initiative may be edited at Women in Data® Limited’s sole discretion. I consent to the use of my name, likeness, voice, and biographical material about me in connection with the Women’s Health Initiative publicity and related institutional promotional purposes. I expressly release Women in Data® Limited, its agents, employees, sub-contractors, licensees and assignees from and against any and all claims which I have or may have invasion for privacy, defamation or any other cause or action arising out of production, broadcast or distribution of the Women’s Health Initiative.

    IF UNDER 18 I represent that I am a parent (guardian) of the minor who has signed the above release.