CONSENT TO COLLECT AND DISCLOSE PERSONAL

INFORMATION, AUDIO-VISUAL MEDIA

1. Purpose of Collection & Disclosure

1.1 RMIT University seeks consent to disclose personal information in the form of audio-visual filming of
persons for the purpose of Assessment Task 2. The media will be used for learning and teaching
purposes. This media will be uploaded to the students personal e-portfolio.

2. My Details
2.1 Name: Hannah Keel

2.2 Telephone: 0455067744

2.3 Are you over 18 years of age? (tick or check box)

Yes. Go to section 3.
No. Your parent/guardian must complete section 4.

3. My Consent to Collect Personal Information (if over 18)

3.1 I, Hannah Keel consent to RMIT University collecting personal information in the form of audio-visual
images (video).

3.2 My Signature: …………………………………………………………….. Date: 15/8/2019

4. Parent/Guardian’s Consent (if under 18)

4.1 I, ……………………………………………………………… (insert name) consent to RMIT University
collecting my child’s personal information in the form of audio-visual images (video).

4.2 Signature of Parent/Guardian….………………………………………….. Date: ……/………/20……

5. Privacy Statement
Your personal information collected is used for the students completion of Assessment Task 2 as described
in section 1 above. Your personal information will only be used or disclosed for these purposes, or where
required to by law. You may request your information to be amended or you may withdraw your consent for
future disclosure by contacting Kylie Spencer (1st year coordinator), kylie.spencer@rmit.edu.au.
Alternatively, you may contact RMIT University’s Privacy Officer.

Your personal information will be collected and/or stored with the following RMIT University department(s):
Osteopathy department, as part of the School of Health and Biomedical Sciences

OFFICE USE ONLY

File Reference: ……………………………………………………………..Photograph Number: ………………………………...
Description:
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Copy of form to be kept by department collecting personal information