Media consent form

Thank you for sharing your story.

Stories like yours play a vital role in raising awareness of the real, human impact of spinal cord injury.

We produce a wide range of materials to promote our mission to cure paralysis. By signing this form, you are agreeing that we can share your story and your likeness to help us raise awareness and vital funds to further our mission or in other campaigns that will benefit Spinal Research.

Thank you.

Consent details

Consent for use of photos/videos/stories

Please enter the details of the person giving permission below:

First Name

Last Name

Phone number

Address line 1

Town/City

Country

State

Province

County

Zip/Postal code

Date of birth

Upload your photo

Parent/Guardian consent

If completing this form on behalf of a child, please provide your details below.

Childs First Name

Childs Last Name

Relationship to child.

Your contact details (if different from above):

Phone number

Your connection to Spinal Research

Connection to Spinal Research

Injury level

Injury severity

How injury occurred

Year injured

Mobility impairment

Communication preferences

We would love to keep you up to date with all the latest Spinal Research news and information. If you'd like to receive our updates please let us know how you'd prefer to receive them:

Phone

Text message

By checking these boxes and submitting this form, you are agreeing to join our contact lists. We'll only send you information related to Spinal Research. Your privacy is important to us and we process your personal data in accordance with the UK GDPR. You can unsubscribe at any time. For more information about our privacy practices, please visit our website.

Conditions of use

This form is valid for the period of time that Spinal Research uses the photos, videos, or stories of you and/or your child/children's likeness in any of its marketing and PR activities (social media, website, literature and print, etc.). This form allows us to use your story and image free of charge.

Your Rights

You can withdraw your consent at any time by emailing info@spinal-research.org. We will stop using your likeness in new materials and will do our best to remove it from existing materials. Previously printed or published content may not always be removable.

Personal Information

Your contact details will never be shared publicly or with third parties for commercial

purposes. For more details on our privacy policy, visit spinal-research.org/privacy

Contact Information