Share your story - Questionnaire and consent

To raise awareness of brain injury and its impact, Synapse works with individuals in our community to share their story. These stories speak to each person’s journey living with a brain injury, celebrates their achievements, and acknowledges the commitment given to them by their families and the community they live in.

Please note by completing this form you’re acknowledging that you’re comfortable with Synapse contacting you to write and publish your story on its channels to its audiences. This may include – but is not limited to –Synapse’s social media, website or marketing emails. Publishing of each story is at the discretion of Synapse team. Please do not include any information you’re not comfortable to share in a public setting.

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    Your Name*
    Your location*
      Preferred method of contact
        Max. file size: 512 MB.
          Please indicate if you would like your identity to remain anonymous*
          Upon signing this form you give permission for Synapse to use part, or all, of the information provided, either in a written or audio-visual format. You also understand that this may include campaigning, education and revenue-generation purposes and may take the form of – but is not limited to – social media, email communication, printed materials, media and online stories, film and audio, advertisements, public education, interviews and presentations.
          By typing your full name below, you are electronically signing this form