Consent and information sharing form -

Please read the MRSN Consent & Information Sharing Leaflet by clicking here.

If you have any questions about consent, please contact Kashif at kashif@mrsn.org.uk or call on 07592 383221 before completing the form below.

I have read and understood the MRSN Consent & Information Sharing Leaflet.

Yes No

I hereby give my permission for (MRSN) to share personal information with other service providers in connection with my support into volunteer placements. I understand that (MRSN) may hold information gathered about me from the various agencies I volunteered with or was signposted to volunteer and from information I have provided to MRSN and understand my rights under the Data Protection Act will not be affected.

Statement of consent

I understand that personal information is held about me.

I have had the opportunity to discuss the implications of sharing or not sharing information about me.

I agree that personal information about me may be shared and gathered from agencies I volunteer at or am referred to volunteer.

Storage of personal information

I agree to my information being stored on MRSN electronic case management system and papers being stored securely in locked filing cabinets, and for the sharing and gathering of information between services.

I agree to my information being used for MRSN funding bodies for statistical and monitoring purposes. I am aware my personal information will be anonymised.

I understand that my consent to share personal information is entirely voluntary and I may withdraw my consent at any time. Should I have any questions about this process, or wish to withdraw my consent, I can contact: Kashif Ali (kashif@mrsn.org.uk) or the Shared Routes team at 07592 383 221.

Name

Date of birth

Post code

Full name as signature

Date of signature

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