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bibic
Changing Children's Lives
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bibic developmental therapy
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Johansen Individualised Auditory Stimulation
Irlen Syndrome
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Consent form
Consent Form
Consent form
We will contact you via email. We will keep your information secure. You can change how we contact you at any time via info@bibic.org.uk, 01458 253344 or writing to bibic, Old Kelways, Somerton Road, Langport, TA10 9SJ
Parent/ carer full name
(Required)
Young persons full name
(Required)
Consent to be contacted by our Marketing department
(Required)
Free Live Q&A’s
Training sessions
Newsletter
Events
All
None
If you would like us to keep in touch about our upcoming free monthly Live Q&A’s, training sessions, events, newsletter, please select your preferences
Consent to be contacted by our Fundraising department
(Required)
Yes
No
bibic need to raise £1,320.73 towards the cost of every full assessment, therapeutic plan and support for families. We would like to keep in touch with you about fundraising. I consent to bibic contacting me about fundraising events, appeals and activities.
Permission to use your bibic journey in an anonymous case study to report to our supporters and funders in our Trustees report and other materials
(Required)
Yes
No
Would you be happy to share your experience of your bibic journey?
(Required)
Yes
No
Sharing your bibic experience allows us to reach more families who need support, if you are happy to share your experience, you may select where we share this below below.
Please select the following:
(Required)
Permission to use first name and photos
Permission to use anonymously
Where would you be happy for us to share your bibic experience?
(Required)
Website
Social Media
Trustee Annual report and other printed media
To our supporters and funders
All
At the end of keyworking, we will send you a survey. Would you be happy to participate in any further surveys?
(Required)
Yes
No
Signature
(Required)
Signature date
(Required)
