Permission Form
Action on Elder Abuse Helpline No: 080 8808 8141
Astral House. 1268 London Road, Admin No: 020 8765 7000
London England. SW16 4ER. 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
___________________________________________________________________