Peer Navigator Application Form -

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

Photography, filming, publicity and data storage consent form

Please complete this form to give consent for us to take images, moving footage, audio, comments and other personal data to then be stored and used. To clarify, we will never use your name in marketing or promotion, in order to stay in line with our confidentiality policy.

This form covers consent for use of the above for internal and external communication and storage of the data within this form. All data (images, film, comments, personal info on this form), will be stored by Manchester Refuge Support Network. The data may be shared with 3rd party organisations in order to fulfil the communication work necessary, e.g. providing images to design/ print agencies.

This form is just for people over 16 years of age.

Full Name

Address

Telephone number

Email Address

Date of birth (if under 16)

I give consent to Manchester Refugee Support Network to publish, republish or otherwise transmit still and moving images and audio for the purposes of:

Publicity and promotional materials, including advertising material and printed publications Presentation and exhibition materials Websites, social media channels and digital communications materials, including advertising material and printed publications News media and their associated websites, social media channels, print publications, television and radio Publication to funders

Terms and Conditions

I understand that Manchester Refugee Support Network will keep all its images in accordance with data protection law and delete the images that have not been used for any publicity or marketing after 2 years. I also understand that the still / moving images / audio used for publicity or marketing purposes are in the public domain and therefore could potentially be reproduced, altered, or re-used by anyone in the world outside of Manchester Refugee Support Network’s control. I know I have the right to withdraw consent at any time by emailing info@mrsn.org.uk but understand that withdrawing consent may not affect the material that has already been used.

Signature/Initials

Date signed