Consent form for adult sharing their story

We publish real-life stories and shorter quotes from Hospice patients, their loved ones, staff and volunteers to help explain our work to the public and encourage them to support us as a charity.

By completing this form, you’re giving us permission to share your story in our communications for two years – thank you. You can withdraw your consent at any time.

I understand the following:

My story and any photos or videos of me will be stored securely by Willen Hospice.
These may be used to promote the Hospice in their printed communications (such as fundraising appeals and supporter magazines), online (on their website and social media channels), in advertising or in the press.
As part of their marketing, Willen Hospice may also pass my story to trusted third parties to use, such as Hospice UK or corporate partner organisations.
My story will be used accurately and honestly, and never taken out of context.
If I say anything that indicates I’m not safe, or someone else isn’t safe, Willen Hospice will help me get support.
By signing, I am confirming that anyone else mentioned in my story, or featured in my photos/videos, knows they are being included and understands these will be published publicly.
My story will be used for two years and then archived, unless Willen Hospice contact me to arrange otherwise.
I can withdraw my consent at any point during that time by contacting stories@willen-hospice.org.uk or 01908 306 695, and my story and any photos or videos of me will be removed from circulation wherever possible.

Consent form

Adult Consent form

First Name(Required)

Last Name(Required)

Address Line(Required)

Address Line 2

City(Required)

State / Province / Region(Required)

Country(Required)

Post Code(Required)

Email(Required)

Phone Number(Required)

Can we use your real first name? You can choose to have your real first name published with your story or remain anonymous.(Required)

Consent(Required)

I consent that my story and photos/videos of me may be used in promotional materials by Willen Hospice.

Data protection

We need to collect your personal data so that we can get in touch with you to discuss your story and/or image use. We promise to look after the information you give us, and it will only be used for this purpose. If you would like to know how we collect, process and store your personal information, our Privacy Notice is available on our website.
If we need to speak with you about your involvement, we may do so via the contact details you have provided.

We promise to look after the information you give us, and it will only be used to manage your support of Willen Hospice.

If you would like to know how we collect, process, and store your personal information, please see our Privacy Notice.

Your ongoing support helps our patients and their families, and we look forward to keeping in touch by post and phone to share our news with you and other ways you can get involved.

Would you also like to hear from us by:

SMS

Name

Address Line

Address Line 2

City

State / Province / Region

Country

ZIP / Postal Code

Phone Number

Can we use your real first name? You can choose to have your real first name published with your story or remain anonymous.

Consent

I consent that my story and photos/videos of me may be used in promotional materials by Willen Hospice.

Data protection

We need to collect your personal data so that we can get in touch with you to discuss your story and/or image use. We promise to look after the information you give us, and it will only be used for this purpose. If you would like to know how we collect, process and store your personal information, our Privacy Notice is available on our website.

Support us

Your donations make all the difference

We need to raise £9.6 million each year to provide our services free of charge.

We’re grateful for every single donation we receive, no matter how big or small. Your kindness means we can continue supporting people in our community during what may be the toughest time of their lives.