Patient partner permission

Contrast:

Kent and Medway Cancer Alliance's patient partner permissions and information form

I would like to join the Kent and Medway Cancer Alliance as a Patient Partner and agree to my information being held by them for the reasons mentioned below.

The Data protection Act 2018 introduced rules to help to protect you and your private data by putting you in charge of what, where, and how information is shared.

We will store your contact details on our secure database so that we can contact you easily and quickly when there is information which we would like to share with you in relation to your role as a Patient Partner.

You have the right to withdraw your consent for Kent and Medway Cancer Alliance to hold your data at any time.

Please contact us by email if you wish to withdraw your consent.

Questions

Note: Questions marked by * are mandatory

* I agree to the above processing

*This is a mandatory field.

Your name

*This is a mandatory field.

Your home address

*This is a mandatory field.

Your postcode

*This is a mandatory field.

Your telephone number

*This is a mandatory field.

Emergency contact details

*This is a mandatory field.

Does your emergency contact know of your involvement as a patient partner?

Yes

*This is a mandatory field.

How would you like to receive information?

Telephone

Tell us if you have any information or communication needs.

*This is a mandatory field.

How have you been affected by cancer?

Patient

Family member

Carer/supporter

Friend

*This is a mandatory field.

What type of cancer do you have experience of?

*This is a mandatory field.

How would you like to be involved?

Be a virtual member

Join the Working Together Group

Focus groups

Kent and Medway Cancer Alliance may take photographs at events and/or draw on material from discussions. Photographs and direct quotations may be published on it's website and social media channels in order to promote its activities.

Question	Yes	No
*This is a mandatory field. Do you consent to have your picture being used in this way?	Yes	No
*This is a mandatory field. Do you consent to have your words being used in this way?	Yes	No

*This is a mandatory field.

From time to time it may be appropriate to share your email address with others within Kent and Medway Cancer Alliance and/or other patient partners. Would you be happy for this to happen?

Yes

Would like to be asked before it being shared

*This is a mandatory field.

Please confirm you have read and accepted our privacy policy.

Patient partner permission

Search the Cancer Alliance website

Kent and Medway Cancer Alliance's patient partner permissions and information form

Contact us