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Request to adapt or reproduce material form

Huron Perth Public Health (HPPH) will consider requests from other public health units and not-for-profit agencies for adaptation or reproduction of original HPPH materials. HPPH will review your request and provide a response in writing.

Please refer to the Conditions for granting a request below.

If you are seeking permission to adapt or reproduce more than one work, please complete a separate form for each one.

Your information

Material requested

Format of original work
I am requesting permission to

Project details

Format of adapted/reproduced work

Conditions for granting a request

  1. The grantee acknowledges the original content is the creation of Huron Perth Public Health.
  2. The finished reproduction or adaptation shall bear a credit line.
  3. The grantee shall use the reproduced or adapted content only for purposes specified on this form.
  4. The grantee shall not reproduce, publish, use, copy or distribute the Work except for educational purposes for free distribution and the grantee will not authorize or permit any other person to reproduce, publish, use, copy or distribute the Work without the prior written consent of Huron Perth Public Health.
  5. HPPH complies with the Licence Agreements of stock media image suppliers. As such, HPPH will only provide HPPH content in files, with any licensed photographs or artwork removed. The grantee must then either:
    1. purchase the original image themselves from the supplier, or
    2. select a different image using another supplier
  6. An electronic copy of the reproduced or adapted content shall be provided to HPPH at no cost.

Please note: HPPH cannot consider requests to reproduce materials over which the Health Unit does not exercise proprietary control, including illustrations, artwork or photography used under licence.

By checking this box, I acknowledge that I have read, understand, and agree to the above conditions.

The personal information on this form is collected under the authority of the Health Protection and Promotion Act and applicable privacy legislation. This information will be used for delivery of public health programs and services and may be used for evaluation and statistical/research purposes. Any questions about the collection of this information should be directed to the privacy officer, Huron Perth Public Health, at 1-888-221-2133 or