This form can be used to request a copy of the data/information that we hold about you (the data subject), or to authorise someone to act on your behalf. Your request will be processed within 30 calendar days upon receipt of a completed form and proof of identity. There is no charge for this request.
Please note that completion of this form is not compulsory, however it assists us fulfil your request by ensuring that all required information is provided. If you choose not to use the form below, you can also submit your request by emailing email@example.com. To ensure we provide you with the information as quickly as possible, we ask that you provide us with as much information as you can - using the form below as a guide to which information we require. This includes your full name, address and DOB - for both the requestor and the individual for whom you're requesting information for (if different). Likewise, please provide the ID documents (for yourself and, if different, of the individual you are requesting information for) as shown on the form below.
Identity check: You are required to provide us with evidence of your identity, in the form of two documents. One of these documents should be a birth certificate, passport or driving licence, and the other should be an official letter addressed to you (e.g. bank statement, recent utilities bill or council tax bill). If you have changed your name, relevant documents evidencing the change should be supplied.
If you would like to receive this form by post, or if you would like us to e-mail you a copy of this form, please contact us by e-mailing firstname.lastname@example.org or by calling 01484 411040.
SECTION 1: Please complete your details below (the data subject). If you are applying on behalf of someone else, please fill in the details of the data subject below and not your own:
Please upload proof of identity
SECTION 2: If you are applying on behalf of someone else (i.e. the data subject), please provide details below. Otherwise, skip to Section 3.
Please note that if you are not the data subject, but an agent appointed on their behalf, you will need to provide evidence of your identity – as well as that of the data subject and proof of your right to act on their behalf.
Please upload proof of identity
Please upload proof of legal authorisation
SECTION 3: DECLARATION
Data Subject Declaration:
I certify that the information provided on this form is correct to the best of my knowledge and that I am the person to whom it relates. I understand that the Format Me Not Children’s Hospice is obliged to confirm proof of identity/authority and it may be necessary to obtain further information in order to comply with this subject access request.
Authorised person – Declaration (if applicable):
I confirm that I am legally authorised to act on behalf of the data subject. I understand that the Format Me Not Children’s Hospice is obliged to confirm proof of identity/authority and it may be necessary to obtain further information in order to comply with this subject access request.
Warning: a person who unlawfully obtains or attempts to obtain data is guilty of a criminal offence and is liable to prosecution.
* Please be aware that if you wish us to post the information to you, we will take every care to ensure that it is addressed correctly. However, we cannot be held liable if the information is lost in the post or incorrectly delivered or opened by someone else in your household
Please send this form and proof of identity to:
Information Governance Lead, Forget Me Not Children’s Hospice, Russell House, Fell Greave Road, Huddersfield, HD2 1NH