Consent Details – this can be withdrawn at any time by contacting the office on 01253 393748 or emailing data@blackpoolcarers.org Would you like to receive our magazine? Yes: No: (mark with X) If Yes, how would you like to receive our magazine By post: By email: Would you like to receive information about our trips and Yes: No: activities that may be relevant to you? Photo/Publicity Consent We occasionally use photographs of carers in our magazine, website and other media, to highlight and raise awareness. If you consent to us using your photographs for this purpose, carers’ issues please sign and date below, otherwise leave blank. Signature: Date: Carer’s How did you hear about Blackpool Carers Centre?: Referrer Information Referred by: Organisation: Job Title: Contact No: Signature: Referral Date: Please send the completed form to the address at the top of the first page.
Consent Details – this can be withdrawn at any time by contacting the office on 01253 393748 or emailing data@blackpoolcarers.org Would you like to receive our magazine? (mark with X) Yes: No: If Yes, how would you like to receive our magazine By post: By email: Would you like to receive information about our trips and activities that may be relevant to you? Yes: No: Photo/Publicity Consent We occasionally use photographs of carers in our magazine, website and other media, to highlight carers’ issues and raise awareness. If you consent to us using your photographs for this purpose, please sign and date below, otherwise leave blank. Carer’s Signature: Date: How did you hear about Blackpool Carers Centre?: Referrer Information Referred by: Organisation: Job Title: Contact No: Signature: Referral Date: Please send the completed form to the address at the top of the first page.
Adult-Carer-Referral-Form-with-fields-0418.docx