Parkinson's UK consent form (under 18s)

From the date that you sign this form, you will be giving us permission to share your content in accordance with your preferences for the following 3 years. This content includes your written story and quotes from you, as well as films, images, audio, and/or recordings of you. It may be owned and donated by you, or created by Parkinson’s UK.

If you have any questions, please email [email protected].

First name

Last name

Address line 1

Address line 2

Town or city

Postcode

Phone number

Email address

We'll never disclose your email address to others.

Date of birth

We'll never disclose your age without your consent, but it helps us monitor diversity within our storytellers.

Your consent preferences

What is the name of the staff member at Parkinson’s UK that contacted you about this consent form?

Your restrictions and comments

Your content will not be used for any longer than 5 years. You can ask us to stop using it before then by emailing [email protected]. The consent form and any content you have shared with us will be stored on a secure system. Once your consent expires, we will either be in touch to renew it or we will archive (keep, but not use) your content and associated records for 3 years after your consent expiry date or the date you withdraw consent.

Please select each of the boxes below to indicate your explicit consent for your contact details and for your content to be stored, and shared, by Parkinson's UK in our communications:

I understand that my material will be stored and used for up to 5 years unless otherwise specified below.

You must request my permission each time you wish to use my content. (please be assured that if your content is going to be used in the media or mass market advertising you will be contacted to ensure you are happy for it to be used in this way.)

Any other restrictions

If you have any other restrictions or comments, please let us know.

Should we use your real name?

You can choose to have your real name published with your story or remain anonymous.

I am happy for my real name to be used in promotional materials for Parkinson’s UK.

I do not want my real name to be used, please use this fictional name

Fictional name

Only fill in this field if you do not want your real name to be used.

If you are under 18 years of age, your parent or legal guardian must sign this form on your behalf.

Name of parent or guardian consenting on your behalf

Date

You can withdraw or change consent for the use of your story and/or media at any time. If you no longer wish to share your story, or want to change how it is used, contact us at [email protected] and we will act on your decision within 30 days. It may not be possible to withdraw materials already published or issued before you withdrew consent.

More information on our Privacy policy is available on our website at parkinsons.org.uk/privacy

Thank you for sharing your story and helping grow a movement that will stop Parkinson’s. Forever.

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How will Parkinson's UK share my story, photos, audio or video?

These materials may be used by Parkinson's UK in our communications, including:

marketing
newsletters
publications
press releases
websites
briefings
mailings
social media
advertisements
training and audio-visual productions

These materials will not be used by anyone else except subcontractors acting on our behalf. These materials will be used in the UK and Isle of Man and on websites that can be accessed from anywhere in the world.