Consent form: Sharing your story

Thank you for sharing your story

By allowing us to share your story and photos on social media, our website and in our marketing materials, you're raising awareness of the amazing work that happens every day at North Bristol NHS Trust.

Please complete this form to confirm you're happy for us to use your story to raise money for our hospitals, staff, patients and research.

If you have any questions, please email Rebecca Davy at rebecca.davy@nbt.nhs.uk.

First Name*

Last Name*

Email*

Phone*

Date of Birth*

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

May we explore using your story and photos to promote fundraising with third parties, or with the media?*

We will not share anything with third parties, such as media, without your express permission.

Yes
No

Permission & rights granted
By signing this consent form, I am allowing Southmead Hospital Charity to use my story, through text, photos, videos, audio, transcripts and any other materials in which I may appear.

I understand that the Charity may use my information for promotional and fundraising purposes, including in print, and across social media, website, marketing materials and any other digital channels not listed.

I understand the Charity may need to edit, alter or otherwise modify materials to improve their success and confirm it can use my materials indefinitely.

I allow any materials in which I appear to be reproduced without limit and release Southmead Hospital Charity from liability associated with their use, detailed in this agreement.

I understand my permissions are governed by the laws of England.

I acknowledge that the charity respects my privacy and will not disclose any of my information to third parties without my permission according to the Data Protection Act 2018 (DPA 2018), and the UK General Data Protection Regulation (UK GDPR).

I confirm that I have read, understood and give you consent to use my story and photos*

Yes
No

Keeping in contact with you

Marketing permissions

We would like to contact you in the future about the impact of your generous support. If you would prefer not to hear from us in the future, you can opt-out using the tick boxes below.

No, I don't want to be contacted by post
No, I don't want to be contacted by phone

Email marketing

We would like to email you about other ways you can help support the staff and patients at your local hospitals. Please tick the below box to hear from us via email.

Yes, I’d like to hear from you via email

Thank you for sharing your story

Keeping in contact with you

Thank you for your support – it makes a huge difference to our patients, their families and our staff.