CONSENT FORM
For patients' / medical practitioners' consent to publication of material about them or featuring
their image, photograph, voice recording, image.
SUBJECT OF ARTICLE / PHOTOGRAPH : ______________________________________
DATE : _________________
I give my consent for photographs and other materials to appear in Médecins sans Frontières
(MSF) publications. I indemnify the photographer __________________ and MSF of any claims
against them for use of these pictures.
I UNDERSTAND THE FOLLOWING :
(1) I understand that anonymity cannot be guaranteed. It is possible that somebody somewhere -
perhaps, for example, somebody who looked after me if I was in hospital or a relative - may
identify me.
(2) The material will also be placed on the MSF's world wide web sites. At the moment these sites
are open to everybody for free.
(3) The material may also be used in printed publications from MSF.
(4) The material will not be used for advertising or packaging.
(5) Images may be used in news stories in print or online versions by the photographer
_________________________
Signed : __________________
I also give consent for the material to be used in other publications that may
approach MSF so long as the following criteria are met:
(1) The material will not be used for advertising or packaging.
(2) The material will not be used out of context - for example, a picture will not
be used to illustrate an article that is unrelated to the subject of the photograph.
Name: __________________ Signature: __________________
Address: __________________ Date: __________________
Photographer: __________________ Photographer's signature: __________________