Your Story

Publicity Consent Form

Inspiring Kiwis to give blood

Thanks for sharing your story and inspiring Kiwis to donate! Please complete this form in order to be featured
on our website, social media or any other shared communication. In this form NZBS refers to New
Zealand Blood Service, Organ Donation New Zealand (ODNZ) and New Zealand Bone Marrow Donor Registry (NZBMDR)

First Name*

Surname*

NHI Number

By providing your NHI number, you are giving consent for NZBS look up and confirm your use of blood components and products.

Email address*

Phone Number (min. 9 characters, no spaces)

Date of Birth*

*required to be completed

Next Step

We'd love a photo of you if you have one.

Please make sure your photo is less than 4MB and has finished uploading before clicking 'Next Step'.

Image

Max image size - 4MB. Allowed file types - jpg, png

I am the person in the picture or video.

I have permission to upload this picture or video.*

Last Step Next Step

Please confirm the following before providing your consent

Is there anywhere you do not want your story to be shared? Such as television, social media, etc:

Permission for interview / photograph / film:

I give permission for NZBS/ ODNZ / NZBMDR (or any person or agent acting on behalf of NZBS) to interview me (including photographing and/or filming me), and to use the information obtained from me (“Information”) for the publicity purposes summarized below.

I confirm that any Information provided by me within the interview will be accurate and not misleading.
I acknowledge that no payment will be made to me by NZBS/ ODNZ / NZBMDR or anyone else for the Information or for participating in any photography or videography.
I agree that NZBS/ ODNZ / NZBMDR may edit the Information, provided that NZBS/ ODNZ / NZBMDR does not misrepresent the Information that I have given them.
I understand that NZBS has the discretion as to whether it uses the Information.
I give permission for the Information to be used until I tell NZBS/ ODNZ / NZBMDR in writing that they are no longer entitled to use it for any new publicity purposes. I acknowledge that any existing commitments that utilise the Information will not be affected. I acknowledge that any publicity material that has been printed and not yet distributed may be used until printed stocks are exhausted.
I understand that if NZBS/ ODNZ / NZBMDR wishes to use the Information in a way that is materially different to what has been discussed with me, NZBS/ ODNZ / NZBMDR will first seek my permission.

I give permission to NZBS/ ODNZ / NZBMDR for the Information being used for all of the below publicity, unless specifically restricted or excluded in the section below:

Publicity through the local media (e.g. local newspapers, online services etc.)
Publicity through national media (e.g. National TV, Newspapers, online services etc.)
Displaying in public spaces such as hospital waiting rooms, blood donor rooms or mobile blood drives (e.g. as part of posters on the wall).
Displaying on the NZBS website or Facebook page or any other media, or publication in the NZBS annual report. For NZBS use in general publicity material that is provided to people that support NZBS to publicise donations (e.g. at work places or hospital stands, to educate people about blood, organ or tissue donation).

Consent for NZBS/ ODNZ / NZBMDR looking up my health records:

I understand that for the publicity purposes described below, NZBS/ ODNZ / NZBMDR may need to access my health information (including for the purpose of confirming my use of blood components and products), and I authorise such access.

The information collected will be used and held by NZBS/ ODNZ / NZBMDR. For more information about how we collect, use and store your information, please refer to our Privacy Statement, which can be viewed at www.nzblood.co.nz. You have a right to access and request the correction of the information in accordance with the Health Information Privacy Code and related New Zealand law. We take privacy breaches seriously and do everything we can to prevent them from occurring. In the event a privacy breach does occur, we will comply with the notification requirements in the Privacy Act 2020. If you have received information in error or are concerned you may have been the subject of a privacy breach, please contact the New Zealand Blood Service Privacy Officer at privacy@nzblood.co.nz.

Last Step

Step 1 of 3

Processing your consent.

Thank you for giving your consent to allow us to share your story and/or photo. Stories like yours inspire people to donate blood and save and improve the lives of many others undergoing treatment in hospitals across the country.

If you want to talk to us about your online consent form or withdraw consent at any time, please call the NZBS Marketing and Communications Manager on 09 523 6486 or email us at info@nzblood.co.nz.

Please note, you can find the terms and conditions around sharing your story here.

Regards,
The Team at New Zealand Blood Service

Your Story

Inspiring Kiwis to give blood

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