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 - None -FemaleMale Medical history relating to your epilepsy e.g. Your age when you first developed epilepsy, when it was diagnosed, treatment etc. Other Information relating to your epilepsy e.g. health, employment concerns, social misunderstandings, positive/negative experiences etc. Comments please add any details that you would like to submit such as family details, other languages spoken, living arrangements. Would you be happy to be photographed? Yes No 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 Your ethnic group (please tick relevant boxes) 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. Other Asian Asian Asian British Asian English Asian Scottish Asian Welsh Bangladeshi Indian Pakistani Any other Asian background (specify below if you wish) Other Black African Black Black British Black English Black Scottish Black Welsh Caribbean Any other black background (specify below if you wish) Other Chinese Chinese Chinese British Chinese English Chinese Scottish Chinese Welsh Any other background (specify below if you wish) White British English Irish Scottish Welsh Any other white background (specify if you wish) Other Mixed White and Black African White and Black Caribbean White and Chinese Any other mixed background (specify below if you wish) Your religion or belief Which group below do you most identify with? - None -No religionBahá'í faithBuddhistChristianHinduJainJewishMuslimSikhAny other religion or belief (specify below if you wish) Other Other Please select - None -BisexualGay manGay woman/lesbianHetrosexual/straightOther (specify below if you wish) Your sexual orientation Other Your disability The Equality Act 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 Equality Act (2010)?? - None -YesNo 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? 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. 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. 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
