<p>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.</p><p>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.</p><p>This form is a request to film or photograph on site – it does not constitute a location agreement or imply permission to film/photograph.</p><p>Details of person making request Name: Job title: </p><p>Tel: Mobile: Email: </p><p>Production company details Company name: </p><p>Co-production/On behalf of (eg broadcaster): </p><p>Production company address: </p><p>Address for invoice (if different): </p><p>Production details Project title (can be working title): </p><p>Purpose of filming/photography (tick as appropriate): Documentary feature film tv news advertisement commercial promo student other If other, please provide details: </p><p>Has this project been commissioned? Broadcast date/channel: Audience: </p><p>Where and what would you like to film/photograph (provide as much detail as possible):</p><p>Dates and times: </p><p>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: </p><p>Where else are you filming/photographing? Who else are you interviewing? </p><p>Number of crew: Names and titles (this must be provided at least 24 hours in advance of anything taking place on site): </p><p>If your request is accepted, who will be the most senior person attending the site: Name: Tel/mob: </p><p>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.</p><p>Equipment you intend to bring with you (provide as much detail as possible, including quantity, type, size, wattage, weight and mains/battery): </p><p>Are there any other requirements: </p><p>Parking – please note that you will need to make your own parking arrangements.</p><p>Public liability You will need to provide a copy of your public indemnity insurance before any request can be considered.</p><p>Signed: Date: </p><p>Name (PRINT): </p><p>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</p>
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