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User Contribution form

This form is for users to submit stories and poems that may feature on the website in a section for user generated content. We are looking for things that are related to FM. They can convey how FM has affected your life, or how you have battled to overcome circumstance. They can be funny or they can be sad.

Press Stories

From time to time we are contacted to provide people or stories that may feature on a newspaper piece, or and radio show. We often need to be quite specific for these requests as they are looking for a "type" of person to fit their story. These requests are often at short notice so we hope to have these on file so that we can reply quickly. We may also contact you for a photograph.

General Contact details

Name:

*

Email Address:

*

Phone Number :

Address :

Town /City :
County :

Postcode :

Details for media contact

(only fill this in if you are leaving a personal story that may be used for a media contact)

Is this a media story

Yes No

Age

Gender

Male Female

Marital Status

Do you have any Children?

What are their ages?

How long has your FM been diagnosed?

How long did it take to get diagnosed?

How many Dr's did you see?

Did you give up work/career due to FM?

Yes No

Are you working at the moment?

Yes No

What medication are you on?

What other conditions do you have if any?

Content

This is for both the media contacts and for user submitted content.

What type of Content is this?

May we contact you?

Email Phone Post No

How can we use this content?

Post on website
Use on newsletter / magazine
Allowed to be used by support groups
Pass onto media e.g. newspaper

Submitted content:

Agree to Terms and Conditions
of content submission.

Accept
Disagree *