Form Builder

Required fields are marked with asterisks (*)

Photo and Video Consent

All fields labeled with a star are mandatory and must be completed before your application may be submitted.

First Name

Last Name

Phone Number

Event or Location?

Email Address

Re-Enter Email Address

Personal information on this form is collected under the authority of the Municipal Act 2001, S.O. 2001,c.25, as amended and will be used to administer individual consent for use of video and/or audio recordings and photographs. Questions about this collection should be directed to: Communications and Community Engagement, City Hall, 58 Dalhousie St, Brantford, Ontario N3T 2J0, 519-759-4150, communications@brantford.ca

I provide consent for The Corporation of the City of Brantford to use my image captured on video/photographs(s).

Yes

By selecting “yes”, I provide my consent to The Corporation of the City of Brantford (“City) to use my image captured on video/photograph(s) for the City’s communication and promotional purposes. The City may, at any time, reproduce, publish and/or republish the video/photograph(s) for any communications, advertising, and/or promotional purposes, including posting the video/photo(s) on the City’s websites and the distribution of the City’s communication and/or promotional materials on which the video/photo(s) is used to any third party. However, the City shall not sell or transfer the rights to use my image on the video/photo(s) to any third party without my express consent. I also understand and agree that I will receive no monetary compensation for such use.

Consent for a minor

I provide consent for The Corporation of the City of Brantford to use the below-named minors’ image captured on video/photographs(s).

Yes

By selecting “yes”, I provide my consent to The Corporation of the City of Brantford (“City) to use the images captured on video/photograph(s) for the City’s communication and promotional purposes. The City may, at any time, reproduce, publish and/or republish the video/photograph(s) for any communications, advertising, and/or promotional purposes, including posting the video/photo(s) on the City’s websites and the distribution of the City’s communication and/or promotional materials on which the video/photo(s) is used to any third party. However, the City shall not sell or transfer the rights to use the image on the video/photo(s) to any third party without my express consent. I also understand and agree that I will receive no monetary compensation for such use.