Consent form for European Social Fund case study
Promoting the European Social Fund (ESF)
We (insert NAME OF ORGANISATION) would like to use your recent experience as an example to tell others about the European Social Fund. We call this a case study or good news story and it is used to show how ESF is helping people to improve their 
skills and move towards or into employment. 

How will my story be used?
•	We may use your case study in newsletters, magazines, leaflets or on our website. We would like to use your photograph to accompany your case study wherever possible. Occasionally, we might want to interview you to gather more information.
•	We may refer to your case study on a radio station or on TV. 
•	We may use your case study in local and sometimes national newspapers.  
•	We may share your case study with the Department for Work and Pensions (DWP) European Social Fund Division (who manage the ESF programme in England) and our partner organisations (e.g. insert NAME OF CFO) and/or the European Commission to help them publicise ESF using measures described above.   
•	ESF Division may share your case study with DWP and other Government Ministers who sometimes use case studies when speaking in Parliament or making speeches.

We will share your written case study or press release with you before we start to use it for publicity activity
CONSENT SECTION
Part 1 – For completion by the person either giving or seeking consent
Name of person giving consent: (print name clearly)		
Name of ESF provider and contact information (email and/or phone) 		
Part 2 – Must be completed by person giving consent
We need your consent before we can use your story.
Please tick () the boxes below where you agree to give your consent:
I give my consent for NAME OF ORGANISATION and national, local and other ESF partner organisations to use my case study in the following ways:	To use my name	To use
my photo	
In publicity materials – including booklets, digital media (e.g. websites), feature articles (magazines), radio, TV, local newsletters, exhibition stands, posters etc			
In newspaper articles (some articles may also appear on the newspaper’s website)			
In Government Ministers’ speeches or in written reports e.g. DWP annual reports			
Anonymity: In exceptional circumstances we may be able to use your case study without using your real name, for instance, if there are sensitivities around information you have provided. However, this would greatly limit the use of your story in the general media and we may not be able to use it at all.
I agree and understand:
•	My case study may be used for up to 12 months. After this, it will no longer be used in new material.
•	This form will be kept for 24 months. After this, it will be destroyed.
•	I can withdraw my consent to NAME OF ORGANISATION and other organisations using my case study at any time, by contacting NAME OF ORGANISATION at CONTACT DETAILS
•	Giving my consent will not affect any benefit I receive, or any future dealings with any Government department or agency.

Signature of person giving consent:	
Date: