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CONSENT FORM FOR STORY/IMAGE USE
Name of Elder/Speaker
*
Required: Name of the person giving consent/sharing knowledge.
Type of Material (Select all materials covered by this consent)
*
Oral Story/History
Photograph/Image
Video Footage
Artwork
Purpose of Use
*
Education
Research
Community Promotion
Public Art
The reason the material will be used.
Geographical Limit
*
Local Community Only
Regional Use
National Use
Global Use
Where can the material be shared?
Attribution Agreed
*
Yes
No
I agree to be named/credited when the material is used.
Contact for Withdrawal
*
Required: The designated person to contact if consent needs to be withdrawn.
Submit