I want to share my story

Section 1: Contact Details

Name

Fisrt

Last

Gender

Pronouns

e.g: she/her, he/him, they/them

Date of brith

Section 2: Your Story

Thank you for sharing your story with us. Everyone’s experience is important and invaluable to the work that we do. Don't worry about making your story word-perfect; we are always on the look-out for personal details that bring stories to life.

Please select the fields that best describes your breastHealthType with breast cancer:

Please tick all options that apply:

I've been diagnosed with breast cancer I've had a breast cancer scare I have an increased risk of breast cancer due to hereditary factors / a family connection Someone close to me has been diagnosed with breast cancer Other

If other.please specify.

What age were you affected by breast cancer?

Please tell us your story.

How did you notice your symptoms? What did you do when you noticed a change in your chest? Where you’re from How you heard about CoppaFeel! Any prominent elements to your story The age at which you were affected by breast cancer.

Please tell us how this breastHealthType has impacted you.

Things to consider: Has this impacted how you live your life? What advice would you give someone in the same/a similar situation?

Section 3: Consent

Please tick the options from below that you are happy for us to consider using your story for:

Please tick all that apply

Third Parties/Comfelie partners: Comfelie Works with external brand partners who may wish to invite you to be included in a campaign or event Presentations: Comfelie's Internal and External presentations Websites: Comfelie's website and intranet Social Media: Comfelie's social media pages Publications: Comfelie's leaflets, posters, newsletters and other marketing materials Print and online media: National, regional and local papers; magazines and news sites Television and radio: National and regional television; national, regional and local radio

You can choose to have your real name published with your story or remain anonymous (in which case, we will use a false name).

Please tick one of the following options:

I am happy for my real name to be used I do not want my real name to be used

Informed Consent

By completing and submitting this form you agree to give permission for your story to be used by Comfelie! for the purposes you have selected in this form. Anything you put in this application is strictly confidential unless you provide consent for us to share it. We will only use the email address provided here to contact you about your story. We will never use it to send you spam. Promise.

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