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Please describe in as much detail the materials for which permission is sought. This may include Name of the author, publisher or editor, title and editions of material to be reproduced, exact material to be used by reference to page numbers or chapters. include URL links to or attach copies of materials where possible and identify each as numbered attachments.

For example: the RCH website, brochure or poster. If you viewed the content on the website, please provide the page URL. If other, please a provide a thorough description.

Please include the following information: duration of use, form of distribution

Please address each separate item or groups of items where appropriate and provide as much detail as possible.

Where the request contains inadequate information, further information may be sought. Any permission granted will be limited to a licence to use the materials identified in this form and only to the extent identified by the Requested Use. The RCH reserves the right to decline the Requested Use and to approve a more limited Permitted Use.

Please provide any relevant deadline.

I (your name)   confirm that this information is true and correct and that any licence granted by the RCH in response to this Request will be limited to the Materials and Purpose as set out in this form and in accordance with any Terms of Use the RCH may impose, including but not limited to those on the RCH website. See https://www.rch.org.au/rch/about/terms-and-conditions/.

Where this request has been made on behalf of an organisation, I confirm that I have the authority to bind the organisation on whose behalf this request has been made.

Please tick the following box to sign this form

Name:

Date: