Family Story Consent Form - Parent Carer

Personal details

Child's full name (required)

Child’s date of birth (required)

Name of parent/guardian (required)

How would you describe your child’s medical condition (required)

Contact details

Email (required)

Confirm email (required)

Contact telephone no. (required)

Social media handle(s)

Platform

Handle

Platform

Handle

Platform

Handle

Address

Find your address...

Address (required)

Address line 2

Address line 3

City/Town (required)

County

Postcode (required)

Country (required)

Your Story

Are you happy for us to use your child’s first name, age and medical condition to accompany images?

Yes

I confirm that Action Medical Research has my permission to use the photographs/film footage and agreed story developed/commissioned by the charity or supplied by me (e.g. photos, home video clips) for:

Action’s website*

Action’s magazine, newsletter, e-news

Fundraising appeals

Press (printed and online articles)

General materials such as leaflets or posters promoting our lottery, gifts in wills and fundraising events

Presentations about the charity

Videos

Social media (eg Action’s Facebook, Instagram, LinkedIn)*

TV or radio (national or regional)

*Please note, although we manage and can control the content on our social media and online platforms, we are not able to control how it may be used by other social media and online users and outlets

This permission is understood to be given for 3 years and means we may use the approved story and photos/film footage for charity communications during that time. At the end of this time we will contact you to check that you are happy to remain a family story. We will always contact you first should usage involve the press.

Please tick if you feel you might be interested in talking about your experiences at volunteer meetings/events

Please tick if you use social media and would be happy to share Action’s posts/messages

Data protection: The information that you provide here will only be used to contact you about sharing your story in our communications work. We will not pass the details recorded on this form on to any other organisation without your permission. We will not store your data for longer than 3 years without requesting and recording your further permission.

If at any time you would like the photos, film or story to be withdrawn, please contact Grace Wardley in our Communications Team email gwardley@action.org.uk.

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