Image Consent FormPlease fill in this form to give consent for Healthwatch Essex to use your image for marketing purposes across a wide range of channels. Please only complete this form if you are satisfied that the purpose for which the image/footage may be used has been explained to you and you are happy for it to be used without any further approval. Any materials captured will remain the property of Healthwatch Essex.Name(Required) First Last Address(Required) Street Address City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)This form may only be completed by those over the age of 18. Please confirm which of the below applies.(Required) I am over 18 and completing this form for myself I am completing this as the guardian of someone under the age of 18If you are completing this for someone under the age of 18, please confirm their name and their relationship to you.I consent to(Required) having an image or footage of me captured by Healthwatch Essex, giving them the absolute right to use it for a wide variety of promotional purposes the image/footage being used in connection with my story of lived experience the image/footage being used by Healthwatch Essex partner organisationsWithdrawal of consentYou may withdraw your consent at any time by contacting us at: Healthwatch Essex, 49 High Street, Earls Colne, CO6 2QX. If you withdraw your consent, we will not use your image/footage in any new material and will delete your image from our records. However, your image/footage may be retained on existing materials where a) there is a legitimate interest for Healthwatch Essex to maintain the public availability of those materials, b) this legitimate interest is not overridden by any prejudice (damage or harm) to your own interests or fundamental rights or freedoms, and c) where it is not reasonable and proportionate in the circumstances for the publications or materials to be withdrawn. You may request the withdrawal of any publication or material containing your image, for reasons of prejudice to your own interests, fundamental rights or freedoms, by contacting us at the address above. Any such request will be considered by Healthwatch Essex and you will be informed of the outcome. All details of how your data is used and stored is available in our Privacy Policy.Signature(Required)NameThis field is for validation purposes and should be left unchanged.