Case study

1. Your name: Required Question

2. Your age:

3. Your address:

4. Daytime telephone contact number:

5. Your story (please include details of any social care you receive or have received, how easy or difficult was it to arrange, how it is / was funded, the impact of the support you receive, or lack of support you now receive, how this makes you feel and affects your life) Required Question

6. Being able to share your story with the media will help to support Leonard Cheshire Disability campaign work. Please indicate if you would be willing to take part in the following media opportunities, if they should arise.

	Newspaper / magazine interview with possible photograph
	Radio interview
	Television interview and possible filming of day to day activities at a chosen location
	Have your story and possible photograph used in Leonard Cheshire Disability campaign material

Leonard Cheshire Disability will not pass on personal or contact details without speaking to you first. All media requests will be received and considered by the press office and we will be your first point of contact.

7. If you would like to join Leonard Cheshire Disability’s Campaigns Network and receive regular updates of campaigning activities, please tick.

I would like to receive updates