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Adult consent form

Contributor Consent and Release Form

Permission for use of photographs/video/recordings of the Contributor taken by the University of Cambridge (“University”) at or for the Event/Project (“Recordings”) and for use of digital material contributed by the Contributor to the Event/Project (“Contributor Digital Material”) (together, the “Contribution”)

Date of the Event

Event/Project name Event/Project name

Event organiser

Contact details: Address: 15 Chaucer Road,Cambridge, CB2 7EF Email: info@mrc-cbu.cam.ac.uk Tel: (+44) (0)1223 766166

Thank you for contributing to the Event/Project. By signing this form, you agree to the following terms:

1. I consent to the making and use of the recording of my contribution to and participation and performance in the Event/ Project, the nature of which has been fully explained to me. I understand that if I am unsure of the meaning of the terms set out in this Form, the Event/Project Organiser can explain them to me.

2. I grant the following:

(a) my consent to the University and those authorised by the University to make and use images and recordings of me and my performance (my non-property performer’s right) at or for the above Event/Project taken by photograph and/or video/film and/or sound recording (“Recordings”) and a licence of my property performer’s right to use the Recordings, and

(b) a non-exclusive licence to the University and those authorised by the University to copy and make use of digital material I have prepared and submitted to the Event/Project, including but not limited to material I refer to or include in my performance in the Recordings (“Contributor Digital Material”) for the specific purpose of making and disseminating the Recordings and Contributor Digital Material by all means and in all media (in whole or in part, transcribed or otherwise) in perpetuity throughout the world for the non-commercial educational and promotional purposes of the University, such use including but not limited to print and online publication and broadcast, e.g. in University websites and social media such as YouTube, Facebook and Twitter. My preference to where the recording(s) will be hosted is acknowledged in section (c).

(c) Media hosting preference

Internally on the CBU intranet only (hosted on a private server for internal staff viewing only)

In the public domain (YouTube, external CBU website, etc.) and including on the CBU internal intranet

3. To the best of my knowledge and belief, my Contribution will not infringe the copyright or any other rights of any third party or contain any defamatory material. Should my Contribution contain third party material such as others’ text or still or moving images or of anyone inanimage, the copyright/personal datain that contentmay belong to someone else, which means that I agree that I have obtained their permission/licence/consent as applicable to include it in my Contribution and allow it to be usedby the University for the specific purposes set out in Clause 2.

4. I understand that I have the right to withdraw this consent and the use of my Contribution at any time by emailing the Event/Project Organiser named above, in which case the Contribution will not be used in future publications but may continue to appear in copies of the Contribution already in circulation.

5. The information provided in this Form is to be used for the purpose described above and is managed and stored by the University with my consent. Further information about the University’s use of my personal information is at: https://www.information-compliance.admin.cam.ac.uk/data-protection/general-data.

First name

Contributer ("I"/"You") Name:

Surname

Date

Signature

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Name:

Emeritus Prof. Susan Gathercole

Prof. Joni
Holmes

Prof. Duncan
Astle

Prof. Rogier
Kievit

Prof. Kate
Baker

Dr. Tom
Manly

Current role:

Senior Affiliated Scientist and Honorary Unit Member, MRC CBU, University of Cambridge.

Professor of Psychology, University of East Anglia. Senior Affiliated Scientist to MRC CBU, University of Cambridge.

Professor of Neuroinformatics, Department of Psychiatry, and Programme Leader at MRC CBU, University of Cambridge.

Professor of Developmental Neuroscience at Donders Institute, Nijmegen.

Senior Affiliated Scientist to MRC CBU, University of Cambridge.

Assistant Professor of Clinical Genetics

Department of Pathology, and Programme Leader at MRC CBU,

University of Cambridge.

Programme Leader at MRC CBU,

University of Cambridge.

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