Name *

First Name

Last Name

Consent - Aboriginal Voices Project *

By completing this form you are freely awarding the copyright of your story and image (including photo) to Inception Strategies for the Aboriginal Voices Project. By this, you understand that Inception Strategies will use your respiratory health story and photo to create a story page with an illustrated artwork of you and family members if applicable,  for the purposes of developing a community education booklet for our clients, GSK and the Aboriginal community in WA and Australia. 

I consent to the use of my story

I consent to the use of my supplied photos to create artwork to go with my story

Naming *

I am happy for the story to use my real name and also the real names of the other people mentioned

I would prefer the names in my story to be changed to de-identify me

Aboriginal *

I am of Aboriginal descent

Yes

No