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www.annalipiak.com

Version effective from October 20, 2026

This form is an English translation of the Polish document “Zgoda na wykorzystanie wizerunku i opinii”. It has two versions: Version A for adults and Version B for a child (signed by a parent or legal guardian).

VERSION A – ADULT

I, the undersigned: Full name: …………………………………….. Email: ……………………………………..

hereby consent to Anna Lipiak, conducting business under the name Anna Lipiak – Pianist, Pod Kasztanem 84B, 43-344 Bielsko-Biała, Poland, Tax ID (NIP): 6152016671, REGON: 524600674 (the “Creator”), using my image, including my voice, recorded on ………………………. (date) during …………………………………….. (e.g. lesson, concert, recording session, Piano Playing Audit), and/or my testimonial dated ………………………., free of charge, for marketing, informational and promotional purposes, to the extent I have checked below:

☐ Website and social media – publication of photos, video and audio recordings with my image on the Creator’s website and on the Creator’s social media profiles (e.g. Instagram, Facebook, YouTube, TikTok).

☐ Paid advertising – use of the above materials in paid advertising campaigns (e.g. Meta, Google).

☐ Printed materials – use in printed materials (e.g. posters, flyers, concert programs).

☐ Testimonial – publication of my testimonial, signed as follows (choose one): ☐ full name ☐ first name and initial of last name ☐ anonymously (e.g. “A reader”, “A student”)

☐ Translation and editing of the testimonial – translation of my testimonial into other languages (e.g. English) and its editorial shortening, without changing its meaning. Translated testimonials are marked as translations.

☐ AI editing tools – processing of the materials with artificial-intelligence-based editing tools (e.g. color correction, subtitles, translation, cropping), without creating a false or misleading image of me.

☐ AI training (optional, separate consent) – use of the materials to train artificial intelligence tools. Refusing this consent has no effect on the other consents.

General terms

1. The consent is given without territorial limitation and for an indefinite period, and may be withdrawn at any time, separately for each item above.

2. The Creator may make necessary technical adjustments to the materials (e.g. cropping, resizing, quality adjustment), provided that they do not infringe the personal rights of the person concerned.

3. The materials will be used in accordance with good practice, and never in a context that could harm my reputation.

4. After the consent is withdrawn, the Creator will remove the materials from its own channels (website, social media, active ads) within 14 days. Withdrawal does not apply to materials already printed and distributed, or to materials shared further by third parties (e.g. reposts) over which the Creator has no control.

5. I have been informed that giving consent is voluntary, but that without it my image or testimonial cannot be used for the purposes indicated above.

Place and date: ………………………………………… Signature: …………………………………………

(If this consent is given online, checking the boxes and submitting the form replaces the signature.)

VERSION B – CHILD (signed by a parent or legal guardian)

I, the undersigned (parent / legal guardian): Full name: …………………………………….. Email: ……………………………………..

acting as the parent / legal guardian of the child: Child’s full name: ……………………………………..

hereby consent to Anna Lipiak, conducting business under the name Anna Lipiak – Pianist, Pod Kasztanem 84B, 43-344 Bielsko-Biała, Poland, Tax ID (NIP): 6152016671, REGON: 524600674 (the “Creator”), using my child’s image, including voice and musical performance, recorded on ………………………. (date) during …………………………………….., free of charge, for informational and promotional purposes, to the extent I have checked below:

☐ Website and social media – publication on the Creator’s website and social media profiles.

☐ Printed materials – use in printed materials (e.g. posters, concert programs).

☐ Child’s name – the child may be named as follows (choose one): ☐ first name only ☐ first name and initial of last name ☐ no name

The Creator does not use children’s images in paid advertising or for training artificial intelligence tools.

General terms

1. The consent is given for an indefinite period and may be withdrawn at any time, separately for each item above, by the parent/legal guardian or, once they come of age, by the child themselves.

2. The Creator will never publish the child’s surname in full together with information that could reveal the child’s place of residence or school.

3. The Creator may make necessary technical adjustments to the materials (e.g. cropping, resizing, quality adjustment), provided that they do not infringe the child’s personal rights.

4. After the consent is withdrawn, the Creator will remove the materials from its own channels within 14 days. Withdrawal does not apply to materials already printed and distributed, or to materials shared further by third parties over which the Creator has no control.

5. I have been informed that giving consent is voluntary.

Place and date: ………………………………………… Signature of parent / legal guardian: …………………………………………

INFORMATION ON THE PROCESSING OF PERSONAL DATA (Article 13 GDPR)

(Regulation (EU) 2016/679 of the European Parliament and of the Council of April 27, 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC – “GDPR”)

1. The controller of your personal data (and, in Version B, of your child’s data) is Anna Lipiak, conducting business under the name Anna Lipiak – Pianist, Pod Kasztanem 84B, 43-344 Bielsko-Biała, Poland, Tax ID (NIP): 6152016671, REGON: 524600674.

2. For matters related to the processing of your data, please contact the controller at: This email address is being protected from spambots. You need JavaScript enabled to view it..

3. The controller processes the following personal data: image (including voice and musical performance), first and last name, email address and the content of the testimonial, in connection with the consent to recording and publishing the image and testimonial.

4. The data will be processed for the purposes of:

   • publishing and promoting the image and testimonial as part of the controller’s activities (Article 6(1)(a) GDPR – consent);

   • archiving (evidence) to secure information in case it is legally necessary to demonstrate facts, which is the controller’s legitimate interest (Article 6(1)(f) GDPR);

   • establishing, pursuing or defending possible claims, which is the controller’s legitimate interest (Article 6(1)(f) GDPR).

5. Providing data is voluntary but necessary for the above purposes.

6. Processing is based on voluntarily given consent, which may be withdrawn at any time without affecting the lawfulness of processing carried out before its withdrawal.

7. Data may be disclosed to entities authorized by law; providers of IT, hosting and marketing services, to the extent necessary for publication; and to Internet and social media users in connection with the publication of the image.

8. Data may be transferred to third countries (outside the EEA), in particular in connection with the use of platforms such as Meta (Facebook, Instagram), Google (YouTube) or other marketing tools, subject to the appropriate safeguards required by the GDPR (in particular the EU–U.S. Data Privacy Framework and Standard Contractual Clauses).

9. You have the right to request access to your personal data, rectification, erasure or restriction of processing, the right to object to processing, and the right to data portability, in the cases and under the conditions set out in Articles 15–22 GDPR.

10. Your data will be processed until consent is withdrawn. For the purpose of defending against claims, the data may be processed until the limitation period expires.

11. You have the right to lodge a complaint with the President of the Polish Personal Data Protection Office (UODO) or with the data protection authority of the EU Member State of your habitual residence.

12. Your personal data will not be subject to a decision based solely on automated processing, including profiling, that produces legal effects concerning you or similarly significantly affects you.