UCAN Consent Form 2023 18 year olds and over

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Email *

First Name *

Surname of Name *

Date of Birth *

YYYY

Mobile Number *

Home Telephone Number

Address *

Postcode *

Any special requirements? *

Please give details of visual impairment or any other disability or allergies *

What is your preferred method of contact *

Phone

Mail

Text

Important please complete *

Yes

I give permission for photographs or videos taken during this project to be used for evaluation and or publication

I give permission for the information on this form to be recoded by UCAN Productions so I can be informed about other events

I give permission for these details to be kept on the UCAN Database (UCAN will NEVER share your data with any third party)

Statement: I understand that by submitting this form I give permission to be contacted about UCAN opportunities and activities *

Yes

Required

Date *

YYYY

What is UCAN? Listen to one of our members talk about what UCAN is all about.

A copy of your responses will be emailed to the address you provided.

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