Image and story consent form guideline


Policy statement

The policy of ASXL Rare Research Endowment Foundation (AЯRE Foundation) is that where we are planning to use an image (photograph or video film) or/and story (story, testimonial or quote) for materials in the public domain, consent must be obtained by the appropriate person as set out in the following consent form.

Purpose of the consent form

The purpose is to provide information for the person giving consent so they can make an informed decision and to be clear about which areas of work the consent applies to.

Why does AЯRE Foundation needs images and stories?

The AЯRE Foundation relies on donations to fund research that will increase our understanding of the ASXL genes and to improve the treatment of individuals with congenital ASXL mutations. We need photographs, video films and stories to help promote our work .

How are images, stories and testimonials used?

We use images and stories in a range of materials to promote the AЯRE Foundation. This includes (but is not limited to) advertisements and publicity materials (leaflets, brochures, posters, direct mail and publications for the Internet). The AЯRE Foundation will retain copyright of the image and story as part of materials to promote their work.

How long does consent last?

Consent continues with no time limit. Image and story consent can be changes or withdrawn at any time. We cannot withdraw images and stories already published.

Who can give consent?

Only a parent/legal guardian can give consent. A signature by the parent/legal guardian is obtained.




Image and story Consent form


Please print this form, complete and sign it.

Then scan or photograph the form and return it by email to

Or use our "Image and Story Consent Form" below:

I agree to the AЯRE – ASXL Rare Research Endowment Foundation (AЯRE Foundation) using the image(s) and/or story and give hereby the ARRE Foundation permission to publish, use and republish the attached material, in whole or in part, in publications which describe the Foundation’s programs, funds and any of its activities as a community foundation.

The said material may include a photograph(s), video(s), stories, quotes and testimonials (written, audio or video recorded).

The said material may be used before a variety of audiences which may include the AЯRE Foundation’s staff and directors, current and potential donors and grantees of the Foundation, the news media and the general public. Publication may appear in newsletters, annual reports, brochures, posters, website pages, social media or other forms of literature, including electronic and print.

I understand that I may withdraw this consent at any time by forwarding such request, in writing, to the AЯRE Foundation.


Name of Parent / Guardian
Name of Parent / Guardian
Childs Name *
Childs Name

Thank you for completing the consent form. Now please upload your image.