Application to Film Or Take Photographs at Buckinghamshire Hospitals NHS Trust

Application to film or take photographs at Buckinghamshire Hospitals NHS Trust Please complete in block capitals and return to the communications department as soon as possible.

If you are unable to complete all the details on this form you may leave sections blank – however, we may request this information before we make a decision about your request.

This form is a request to film or photograph on site – it does not constitute a location agreement or imply permission to film/photograph.

Details of person making request Name: Job title:

Tel: Mobile: Email:

Production company details Company name:

Co-production/On behalf of (eg broadcaster):

Production company address:

Address for invoice (if different):

Production details Project title (can be working title):

Purpose of filming/photography (tick as appropriate): Documentary feature film tv news advertisement commercial promo student other If other, please provide details:

Has this project been commissioned? Broadcast date/channel: Audience:

Where and what would you like to film/photograph (provide as much detail as possible):

Dates and times:

Will you need to interview/film/photograph any staff or patients as part of this production? If yes, please provide details: Will Buckinghamshire Hospitals NHS Trust be identified? If yes, in what context:

Where else are you filming/photographing? Who else are you interviewing?

Number of crew: Names and titles (this must be provided at least 24 hours in advance of anything taking place on site):

If your request is accepted, who will be the most senior person attending the site: Name: Tel/mob:

Will you require a site visit in advance? Please note that there is £50 charge for site visits, which will be redeemed against the final charge if filming/photography takes place on site.

Equipment you intend to bring with you (provide as much detail as possible, including quantity, type, size, wattage, weight and mains/battery):

Are there any other requirements:

Parking – please note that you will need to make your own parking arrangements.

Public liability You will need to provide a copy of your public indemnity insurance before any request can be considered.

Signed: Date:

Name (PRINT):

Please return to: Communications department, Trust headquarters, Buckinghamshire Hospitals, NHS Trust, Amersham Hospital, Whielden Street, Amersham, Bucks, HP7 0JD [email protected] fax: 01494 734 753