Form cover
Page 1 of 2

Media Consent Form

Full name

I DO NOT CONSENT

I DO NOT CONSENT

I DO CONSENT

I DO CONSENT

Optional: Third-Party Publicity

Optional: Third-Party Publicity

Withdrawal of Consent

I understand I can withdraw consent for future use by contacting info@shockwavejujitsu.co.uk, but that materials already shared or distributed may not always be removable.

Signature

Signature

Date