Case study consent form

Thank you so much for sharing your story. Please fill in this form to consent to Alcohol Change UK using your story publicly.

If you would like to withdraw your consent you can do so at any time by emailing [email protected].

First Name

Last Name

Phone number

We (Alcohol Change UK, registered charity no. 1140287) would like to use your story to support the promotion of our charity to various stakeholders. This means that it may be used on our website and social networks, as well as in our publications. Copy may be edited for length and clarity without further approval being sought from you. We may also send it to recognised media organisations who may use it for publication. If we do so, we will not give out your personal details without your permission. We will aim to re-seek your permission to use your story three years after the date of this release. You can withdraw consent at any time by emailing [email protected]

I am happy for you to use my story as outlined above.

Would you like your case study to be anonymised? Use my full nameUse my first name onlyDo not use my name

Are you happy for us to contact you about media interviews?

You will be able to decide for each interview whether or not you would like to go ahead. If you are interested but would like more information, please email [email protected]

YesNo

Signature

Please type your full name below.

Case study consent form

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