Action on Elder Abuse - Media Permission Form

**Leading the fight against adult abuse**	Need information or support? Call our helpline UK: 0808 808 8141 ROI: 800 940 010
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Action on Elder Abuse

Home	If you are willing to speak to the media about your experiences then please complete the form below, print it out, and forward it to us at the address shown. All contacts will be treated in strict confidence and your contact details will not be passed to the media without your agreement.
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		Media Permission Form
	Action on Elder Abuse Helpline No: 080 8808 8141 PO Box 60001, Streatham Admin No: 020 8835 9280 London. SW16 9BY. Reg Charity No: 104397
	RAISING AWARENESS ON ELDER ABUSE I would be willing to speak to the media about my personal involvement with elder abuse, and understand that my details will not be given to anyone without Action on Elder Abuse first seeking my permission.
	Mr / Mrs / Miss / Ms Last name ______________________________________________ First Name______________________________________________ Address ______________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Tel No: Day time ________________________ Evening ___________________
	Relationship to the abused person e.g. victim, relation, friend, paid worker, etc ___________________________________________________________________ Type of abuse ___________________________________________________________________ Where it occurred ___________________________________________________________________