Consent Form

Your Details

Full Name

Email/Phone

Consent for storing submitted data *

Yes, I give permission to store and process my data

Address *

Are you over the age of 18?

Yes No

What is the name of your Parent/Guardian

Relationship to child

How we may use your photo, video or story

UHNM Charity may use your image, video, or story for:

Our website and social media (e.g. Facebook, Instagram, LinkedIn, X/Twitter, YouTube) Charity printed materials (e.g. newsletters, leaflets, posters) Fundraising and promotional materials Local, regional or national media (TV, radio, press, online news) Once something is shared publicly, others may see, share or copy it, and it may not be possible to remove every copy later. You can withdraw consent at any time by contacting: uhnm.charity@uhnm.nhs.uk

Please tick all that apply

I am happy for UHNM Charity to use my photo/video/story in the following ways: *

On UHNM Charity’s website On UHNM Charity’s social media channels In printed materials such as posters, leaflets and newsletters In press or media coverage (newspapers, TV, radio, online news) In internal materials (e.g. staff intranet, charity reports) My first name can be used with my image/story My full name can be used with my image/story My story or quote can be shared alongside my image

Data protection and your rights

Your personal data will be stored securely and only used for the purposes you’ve agreed to.

We will not sell or share your information with other organisations for marketing. You have the right to: See the information we hold about you Ask us to correct or remove your data Withdraw consent at any time To contact us, please email uhnm.charity@uhnm.nhs.uk or write to: UHNM Charity, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent ST4 6QG

Consent Declaration

I have read and understood this form. I give my consent for UHNM Charity to use my image, video, and/or story as selected above.

If the person is under 18 years old

I confirm that I am the parent/guardian of the child named above and give consent for their image, video and/or story to be used as agreed. (Parent/Guardian signature below)

Signature

Date

UHNM Charity

Royal Stoke University Hospital

Newcastle Road
Stoke on Trent
Staffordshire
ST4 6QG

Phone 01782 676444

County Hospital
Weston Road
Stafford
ST16 3SA

Phone 01785 230948

Email charity@uhnm.nhs.uk

Walk, Run, Swim, Cycle

Fundraise Now!

Are you interested in raising money for the charity and need to know what your next steps are?

Your Fundraising