Connected TEC Community Group Sign-up

Consent Form

Your privacy is important to us, and we want to communicate with our TEC Community group members in a way which has their consent, and which is line with UK law on data protection. Please fill in the contact details you want us to use to communicate with you.

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* 1. Please enter your contact information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. What is your sex?

Male

Female

Prefer not to answer

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* 3. What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

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* 4. Do you suffer from any of the following ailments? (Please select all that apply.)

Allergies

Anemia

Anxiety Disorders

Asthma

Attention Deficit Disorder

Bipolar Disorder

Chronic Dry Eye

Chronic Obstructive Pulmonary Disease

Chronic Pain

Crohn's Disease

Deep-vein Thrombosis

Depression

Gastrointestinal Disorders

High Cholesterol

Hypertension

Hypothyroidism

Insomnia

Neuropathic Pain

Osteoarthritis

Rheumatoid Arthritis

Type 1 Diabetes

Type 2 Diabetes

I do not suffer from any of these ailments

Prefer not to answer

Other (please specify)

By completing this form you are confirming that you consent to Connected TEC holding and processing your personal data for the following purposes (please tick the boxes where you grant consent):

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* 5. I consent to Connected TEC contacting me by:

Post

Phone

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* 6. I agree to the following:

To keeping me informed about news, events, activities and services from Connected TEC (note you can unsubscribe from the Connected TEC e-bulletin at any time);

To including my details in the 'TEC Community Group Directory'

To sharing my details with selected Project Partners so that we can effectively conduct test and pilot projects (you will be notified of the partners we are working with prior to sharing your details)

You can grant consent to all the purposes; one of the purposes or none of the purposes. Where you do not grant consent we will not be able to use your personal data; (so for example we may not be able to let you know about forthcoming services and events, or get you involved in projects); except in certain limited situations, such as where required to do so by law or to protect members of the public from serious harm. You can find out more about how we use your data from our “Privacy Notice” which is available in your Care Service folder located in your home.

You can withdraw or change your consent at any time by contacting the Connected TEC Administrator at Connected Health Ltd. Boucher Business Studios, 3B, Glenmachan Pl, Belfast BT12 6QH or calling 028 9032 9777. Please note that all processing of your personal data will cease once you have withdrawn consent, other than where this is required by law, but this will not affect any personal data that has already been processed prior to this point.

By Submitting this form you agree to Connected TEC holding and processing your data as you have agreed to in this form