Consent and Release Form

- Privacy Notice -

I agree to the following: The Department of Employment and Social Development (ESDC) may use and communicate images/recordings of me for promotional purposes for the #ReducePoverty in Canada contest. This information could include interviews, photos and/or written comments I provide, or any related audio/video recordings or images created for this activity. I understand that ESDC promotions may take place within the Government, or externally with the Canadian public, and could be shared in any format or medium, including the Internet and/or social media (i.e. Twitter, Facebook, Instagram, YouTube and/or LinkedIn). This information may also be shared with federal or provincial government departments and/or with trusted, non-governmental partners.

I also understand that: Any images/recordings of me are collected under the authority of the Department of Employment and Social Development Act and will be retained in a Personal Information Bank called PSU 914 or PSU 938.

By participating in the #ReducePoverty in Canada contest, I consent to having my picture taken, or audio/video recordings made, which ESDC may use and share for the purposes set out above.

Also understand: You are under no obligation to provide your consent, and you may withdraw your consent at any time.

Your consent expires 10 years from this date.

Name of participant __________________________ Signature _________________________

Date (MM/DD/YYYY) _________________________

If being signed for on behalf of a minor by a parent or guardian

I hereby certify that I (name of legal guardian) _____________________ have the full authority to grant consent and release on behalf of (name) __________________________.

X _____________________________  Date _______________________

(signature of legal guardian)   (MM/DD/YYYY)