Multimedia consent and release form

Name *

Start typing your address and select the correct address from the dropdown results.

How would you like to submit your written story to Bliss? *

Feel free to share what you have so far and we will be in touch with you to help you finalise your story.

Would you be happy for the hospital to use your content?

If you are taking part in a video or photoshoot at a neonatal unit, please tick 'yes' if you give your permission for the hospital to use content relating to you and your baby for their purposes as well as Bliss. This includes but is not limited to, the hospital website, marketing materials and social media channels.

Please list anything here. For example, this could include your location, or the age of your children.

Would you be happy for your story to be used as a media case study? *

A media case study is someone willing for their story to be included in a Bliss press release, or to be interviewed by a media outlet about their experience of having a premature or sick baby.

Your story could be used in media outlets including TV, radio, print and news websites. We will contact you before agreeing to anything with a journalist, so you remain in full control and can decide whether you would like to participate.

We will support you at every stage. Agreeing to this means you give us permission to contact you about any future media opportunities.

Have you had any media coverage of your story before?

I give my consent for Bliss and Bliss Scotland to use or capture footage, audio, photographs, words and other types of media (hereafter known as content) involving me and/or my baby.

I give Bliss and Bliss Scotland all rights to use content relating to me and/or my baby in Bliss materials, including but not limited to: Bliss information and marketing materials; on; on Bliss’ social media channels; on co-branded materials in support of Bliss’ aims; on third party websites or broadcast media where the content is about Bliss and Bliss’ work; and in any future Bliss project.

This consent is given indefinitely but I can withdraw it at any time by emailing

I have discussed the above with the child's other parent/s (if appropriate). I am over 18 years of age.
Please tick the box to confirm you have read and agree to the above consent statement: *

Let's keep in touch

Your support helps the most vulnerable babies in the UK. We’d love to keep you updated with news about our work and ways you can get involved with Bliss. Are you happy for us to contact you:
By email *
By phone *
By text message (SMS) *

Your privacy

We (Bliss and Bliss Scotland) promise to keep your details safe and never pass them on to third parties for marketing purposes. Find out how we look after your personal data in our Supporter Promise. If you have provided a postal address we may occasionally contact you by post, but you can opt out of all communications from Bliss at any time by calling us on 020 7378 1122 or emailing