Sustainable Industrial Development for the 21^st Century

integrity – intelligence – innovation

General Media Coverage Consent Form

As part of our networking and promotional activities, Sustainable Industrial Development for the 21^st Century will be inviting newspaper and television reporters to our monthly luncheon meetings. Reporters may want to take photographs or film activities to accompany their stories.

While we will attempt to co-operate with the media when possible and encourage public celebration of our achievements, we recognize there are instances where publicity of this nature is not welcomed by individuals. There will be a table reserved for the media at the front of the room, at our meetings.

When camera people are available, our meetings may be video-taped, so the information can be shared with other members on our members only section of the website.

From time to time, we also update our web page and may wish to include individual or group photos; however we do not provide any personal information on the public section of our website www.SID21C.com. During our luncheon meetings, we also take photographs so that we can share them with others.

You are asked to consider whether you approve or disapprove of yourself possibly appearing in a newspaper/magazine or being televised, or video-taped while attending a SID21C event, being part of the SID21C.com web page or other promotional material or having photos shared with other members. Please check one of the two statements below:

___I consent to being involved in the occasional media coverage and may be part of the SID21C.com web page and other promotional material.

___I do not wish to be involved in media coverage or be part of the web page and other promotional material. (If this is the case, we ask you that you sit at the back of the room during luncheon meetings.)

_________________ _______________________ __________

(Surname, first name) (Participants Signature) (Date)

__________________ _________________________ ____________

(Surname, first name) (Witness Signature) (Date)