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Share my Story

Publicity consent form

Inspiring Kiwis to give blood

Ready to share your story? Great! We just need a few details from you first.

First Name* *

Last Name* *

NHI

Please note that by providing your NHI number you are giving consent for NZBS to look up and confirm your use of blood components and products.

Email address* *

Phone Number

Date of Birth* *

Who asked you to complete this form?* *

*required to be completed

Next Step

We'd love a photo of you if you have one.

Please make sure your photo is less than 4MB and has finished uploading before clicking 'Next Step'.

Image

Max image size - 4MB. Allowed file types - jpg, png

I am the person in the picture or video.

I have permission to upload this picture or video.*

Last Step Next Step

Please confirm the following before providing your consent

Please let us know if there are any ways or places you would not like your story or photograph to be shared. E.g. Television, Facebook.

The information I will provide/have provided to New Zealand Blood Service (NZBS) relates to blood I have received or given, or that a family member or close friend has received or given, from or to the New Zealand Blood Service. I confirm that any information I have provided about any other person who is named or appears in any material I have submitted has given their consent for that information to be provided to NZBS for these purposes.*

I agree to comply with the Terms and hereby give permission to New Zealand Blood Service (NZBS) to use, choose not to use, or edit the information obtained except for any items mentioned above. I agree to be contacted by NZBS in regards to any of the information I have provided. I understand that no payment will be made by NZBS for that information. I confirm that the information obtained from me is up to date and correct.

I give permission for the information to be used, edited in both form and content, and published in any media (eg, TV, print, online), except where I've told you otherwise. NZBS can use, edit and publish this information until I tell NZBS in writing that they are no longer entitled to use it for any new publicity purposes. I acknowledge that any existing commitments that use the information will not be affected. I acknowledge that any publicity material that has been printed and not yet distributed may be used until printed stocks are exhausted.*

Note: you are entitled under the provisions of the Privacy Act 1993 to access and correct any personal information held about you by NZBS. To access or request correction of your personal information please contact the NZBS by writing to The Privacy Officer, NewZealand Blood Service, Private Bag 92071, Auckland Mail Centre, Auckland 1142

*required to be completed

Last Step

Step 1 of 3

Processing your consent.

Thank you for giving your consent to allow us to share your story and/or photo. Stories like yours inspire people to donate blood and save and improve the lives of many others undergoing treatment in hospitals across the country.

If you want to talk to us about your online consent form or withdraw consent at any time, please call the NZBS Marketing and Communications Manager on 09 523 6486 or email us at info@nzblood.co.nz.

Please note, you can find the terms and conditions around sharing your story here: https://nzblood.nz/footer/accessibility-2/.

Regards,
The Team at New Zealand Blood Service

Share my Story

Publicity consent form

Inspiring Kiwis to give blood

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