Online PHOTO / VIDEO Release Form

(NOTE: St. John Ambulance York Region Social Media PHOTO SUBMISSION is HERE
- PARTICIPANT Information -
(The participant is the person appearing in the photos)
Is PARTICIPANT OVER the age of 18 years? *
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- Complete if PARENT / GUARDIAN -
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Is the PERSON in the Photo / Video a registered VOLUNTEER member of St. John Ambulance? *
- Complete if an SJA Volunteer -
Which Branch of St. John Ambulance do you Volunteer / Work?
(Complete ONLY if answered YES to previouse "Member" question) *
Youth Unit ID Number?
(A map has opend below to help you locate the Youth Unit location in York Region to answer this question)

Are you participating in our Social Media Photo / Video Campaign Series?

(More information about this campaign can be found HERE. A new window will open) *
WONDERFUL! - We are so happy to hear that you will be sharing your story with us!
Are you participating in a UK "St. John Journey" / CANADIAN "International Friendship" Proficiency?

WONDERFUL! - We are happy you are participating and can't wait to see your video!
Was there a DOG in the photo?
(Therapy Dog program specific question) *
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- Complete if PUBLIC Spectator -
Generally, what LOCAL REGION where you were photographed?
(Complete ONLY if answered NO to above "Volunteer" question) *
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Please check both boxes below, where applicable: *
• On behalf of myself and/or my child, I give permission to St. John Ambulance to record, film and/or photograph myself and/or my child in connection with my/his/her participation in St. John Ambulance activities or events.

• I agree that all recordings, films and photographs of myself and/or my child that I submit to or that are taken or created by St. John Ambulance (the “Materials”) are the property of St. John Ambulance and may be reproduced, in whole or in part, by St. John Ambulance in any format (including, but not limited to: newsletters, booth displays, brochures, digital media, public service announcements, online newsletters and on the world wide web).

• I agree that the Materials may be used or reproduced at any time at the discretion of St. John Ambulance. I agree that St. John Ambulance may discontinue use of the Materials without notice.

• I agree that St. John Ambulance will exclusively own all rights, including copyright, in the Materials and all components thereof, and that St. John Ambulance may use the Materials throughout the world, in any manner and in all media as St. John Ambulance may deem appropriate.

• On behalf of myself and/or my child, I release St. John Ambulance from any claims or actions that I or my child may have arising out of the use by St. John Ambulance of any of the Materials by any person. I agree that St. John Ambulance may freely assign the rights granted herein to any third party in the sole discretion of St. John Ambulance.
Please check this box: *
(* Age of majority: 18 years in AB, MB, ON, PEI, QC, and SK; 19 years in BC, NT, NU, NB, NS, NL, YU)

PARTICIPANT Digital Signature
Use your Mouse on PC -or- Finger on MOBILE
PARENT / GUARDIAN Digital Signature
Use your Mouse on PC -or- Finger on MOBILE
(Parent / Guardian Signature for Persons under age of 18 years)

Privacy Statement: St. John Ambulance values your privacy.  The information contained herein will be used for the purposes as identified above and St. John Ambulance will only release information to which you have consented.  Please contact privacy@sja.ca for further information on our privacy policy as required.

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