ࡱ> ^a] Ebjbj>> 7$TT%~~8 4h\LTT"vvv1"&W" c"[[[[[[[$^fa \k"!1"k"k" \vv"\'%'%'%k"pvv['%k"['%'%LDx@cPv[f"M&[8\0h\Mfai#aLcPcPawP\ k"k"'%k"k"k"k"k" \ \-$k"k"k"h\k"k"k"k"ak"k"k"k"k"k"k"k"k"~ :  CONSENT FOR USE OF CLINICAL PHOTOGRAPHS AND VIDEOS FOR EDUCATION OR FOR EXAMINATIONS OF THE ROYAL COLLEGE OF PAEDIATRICS AND CHILD HEALTHCase No: I give my permission for the photograph/video which was taken with my permission of me/my child  on at to be used in printed, electronic or video form as part of the Examinations of the Royal College of Paediatrics and Child Health. I understand that the purpose of the Examinations is to help in the selection and training of future GPs and specialists. I understand that these photographs/videos will be kept for an indefinite period if used in exams/training (or for publication if consent is given.) I understand that these photographs will be transferred worldwide in order to enable RCPCH to run examinations for medical practitioners in other countries I understand that I can withdraw my consent at any time.  Name of subject (of photograph/video) in capital letters  DOB of subject (of photograph/video) Name of Parent/Guardian (of subject of photograph/video) (Delete as appropriate)  Address: (Child) Signed: Date:  (Parent/Guardian) Signed: Date: I also agree (please delete) to this photograph or video being published (in any form) for the education of medical practitioners and allied professionals. Signed: Date: (To be completed by doctor) Name (of doctor) in Capital letters: I have explained to my patient/parents of my patient the nature of the above request. I believe that he/she understands the nature of this request and of the consent given. 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