Provincial Office
6111 Cambie Street, Floor 2
Vancouver, BC V5Z 3B2
Tel: 604.321.2652 Fax: 604.321.5316
E-mail: info@bc.sja.ca www.sja.ca/bc
Charitable Registration #10802 2500 RR 0009
Enregistrement charitable #10802 2500 RR 0009
PLEASE PRINT
Media Release Form
Name of Participant: ______________________________________________________________________________________________________________
(and/or) Name of Legal Guardian: ___________________________________________________________________________________________________
Mailing Address: __________________________________________________________________________________________________________________
City: ____________________________________ Province: _____________________ Postal Code: ___________________ Country: ____________________
Home Phone: __________________________________________________________ Work Phone: _______________________________________________
Email: ________________________________________________________________ Organization: ______________________________________________
Please check the applicable boxes:
I acknowledge and consent to the following terms and conditions:
• On behalf of myself and/or my Dependent (where “Dependent” is defined as a minor or a person otherwise legally unable to grant
permission on their own behalf), I give permission to St. John Ambulance (British Columbia and Yukon) to record and reproduce through
print, electronic, or digital media, images of myself and/or my Dependent for use by St. John Ambulance (British Columbia and Yukon) in
publications such as Annual Reports, Fund Raising Pamphlets, Training Materials, Posters, Newsletters and other promotional and
communication materials consistent with these purposes.
• I agree that all print and/or digital media of myself and/or my Dependent that I submit to, or that are taken or created by St. John
Ambulance (British Columbia and Yukon) , “The Materials”, are the property of St. John Ambulance (British Columbia and Yukon) and
may be reproduced, in whole or in part, by St. John Ambulance (British Columbia and Yukon) in any format including, but not limited to,
print collateral (i.e. newsletters, brochures, sell sheets, booklets, publications, documents, display and signage) and electronic collateral
(i.e. web sites, web pages, electronic newsletters and promotional emails, public service announcements including radio and/or television,
as well as video and/or film).
• I agree that The Materials may be used or reproduced at any time without notice and at the sole discretion of St. John Ambulance (British
Columbia and Yukon).
• I agree that St. John Ambulance (British Columbia and Yukon) will exclusively own all rights, including all forms of copyright, of The
Materials and all components thereof, and that St. John Ambulance (British Columbia and Yukon) may use The Materials regardless of
geographical area or region for the purposes identified above.
• On behalf of myself and/or my Dependent, I waive any rights of compensation or ownership of The Materials.
• On behalf of myself and/or my Dependent, I agree that St. John Ambulance (British Columbia and Yukon) may publish or reproduce
either/or my name or the name of my Dependent in connection with The Materials for the purposes identified above.
• On behalf of myself and/or my Dependent, I release St. John Ambulance (British Columbia and Yukon) from any claims or actions that I or
my Dependent may have arising out of the use of The Materials by St. John Ambulance (British Columbia and Yukon).
Authorization
The “age of majority” is legally defined as a person of at least 18 years of age in AB, MB, ON, PEI, PQ, and SK, or a person of at least 19 years of age in
BC, NT, NU, NB, NS, NL, YU (Canada only).
I am the age of majority and I am signing on my own behalf.
I am the age of majority and am the parent or legal guardian of my Dependent and I am signing on behalf of my Dependent.
Relationship to Dependent: _________________________________________________________________________________________________________
Your Privacy
St. John Ambulance (British Columbia and Yukon) values your privacy. The information contained herein will be used for the purposes identified above. St. John
Ambulance (British Columbia and Yukon) will only release information to which you have consented or is required by law. For information regarding St. John
Ambulance’s national privacy policy, please contact
privacy@sja.ca For information regarding St. John Ambulance (British Columbia and Yukon) provincial
privacy policy, please contact our Privacy Officer in British Columbia, at
privacyofficer@bc.sja.ca or call 1.604.321.2652.
PLEASE PRINT
UNIT/APT/STREET NUMBER
STREET NAME
PLEASE PRINT
