Become a media volunteer

Yes... I would be happy to talk to the press about my story:

Name: *

Address: *

Postcode:

Country:

(At present, we are only looking for people in the UK)

Daytime phone number:

Evening phone number:

Email address:

Date of birth:

(dd-mm-yyyy)

Sex:

Medical history:

Other Information:

Comments:

Would you be happy to be photographed?:

Yes

What's your preferred method of contact with Epilepsy Action and/or journalists (mobile phone, home phone, fax, email etc)::

Is there a particular time of day you would prefer to be contacted?:

Data protection agreement

Your data will be kept on our systems for one year. After this time, it will be reviewed and you will be asked if you wish for your records to be removed. If you do wish for the information to be removed, your name, area and telephone number will be kept so we know not to contact you, should you be suggested for media work.
Should you wish to be removed from our records at any time, please contact us and tell us.
The information provided by you to Epilepsy Action will be used for the benefit of Epilepsy Action and people with epilepsy. This may be passed to journalists, whilst maintaining your anonymity, prior to gaining your consent.
Any published information will have entered the public domain, and once there, may be picked up and used for other articles without Epilepsy Action’s explicit consent. Epilepsy Action cannot be held liable for this eventuality.
The information provided by you will be used for articles in a wide range of media formats around the world, i.e. newspapers, publishing, web pages, electronic publishing, television and radio.
You undertake to keep us updated with accurate details.

If you're happy with this agreement, please click in this box: *

Yes

The answers to the following questions are optional. However, they may help to increase opportunities for further media coverage and to raise awareness of epilepsy.

This information is helpful to Epilepsy Action’s press team because we often receive requests for specific media volunteers, which include some of the criteria below.

Answers also help to reflect diversity and provide journalists with the chance to talk to ALL people with epilepsy.

Your ethnic group (please tick relevant boxes)

Other:

Mixed:

White and Black African

White and Black Caribbean

White and Chinese

Any other mixed background (sepcify below if you wish)

Other:

Your religion or belief

Which group below do you most identify with?:

Other:

Your sexual orientation

Please select:

Other:

Your disability

The DDA defines a person as disabled if that have a mental or physical, which has a substantial and long term impact lasting or is expected to last at least 12 months and an adverse effect on the person’s ability to carry out normal day-to-day activities.

Do you consider yourself to have a disability according to the terms given in the DDA (Disability Discrimination Act 1995)? :

If you have answered yes, please indicate the type of impairment, which applies to you (by ticking next to it below). This may help, for example, if you need extra time to understand or remember information. Our media volunteers often have to travel to interviews so we need to ensure accessibility and do all we can to help your experience run smoothly.

Please select:

Do you have any physical impairment which makes it difficult to get around?

Do you have a sensory impairment which makes it difficult to have a conversation or to read information?

Do you have any mental problems or mental illness?

Do you have a learning disability or problems with understanding or remember information?

Do you have any long term illness or medical condition such as asthma, cancer, diabetes, epilepsy, heart disease or HIV?

Do you have any other medical condition or impairment?

Thank you for completing our form.

What Happens Now?

Once you click on 'Submit', your details will be sent through to the press office here at Epilepsy Action. They will be held on file until we get a request from a journalist where we think your story is suitable for the journalist's requirements. At that point we will contact you to ask if you would be happy to talk to the journalist.

We will not pass your contact details on to any journalist without speaking to you first.

If you have any questions about being a media volunteer, please contact Epilepsy Action's press office:

Phone: +44 (0)113 210 8800
Fax: +44 (0)113 391 0300
Email: press@epilepsy.org.uk

Epilepsy Action privacy policy

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International +44 113 210 8850
Email: helpline@epilepsy.org.uk
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