Channel 4 Health Debate
On June 24th Channel 4 & Mentorn Media are holding a special TV debate focusing on health, one of the big issues in this year’s general election. You could be in our audience, possibly telling your story and helping grill senior politicians on their plans for the NHS.

We are keen to hear from all members of the public, from voters of all parties. Also - if you have a recent experience of the NHS you want to share, or work in the NHS or healthcare more broadly and want your voice heard.

The programme will be recorded on the evening of Monday 24th June in West London.

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1. Your Details
Full Name *
Phone Number *
Email Address *
Full Address and Postcode *
Are you aged 18 years or over? *
Age *
Have you ever appeared on a television programme before? *
If yes – what was the programme and when was it? (optional)
What is your gender? *
What is your occupation (if retired what was your profession before retirement?) *
To which ethnic group do you belong? *
 Do you consider yourself to have any disabilities? *
2. Your Views
Have you or a loved one had a recent NHS experience you would like to share ? *
If so can you describe your experience briefly here?
Are you available & able to travel to London for an evening recording on Monday June 24th? *
How do you intend to vote in this year’s general election? *
Name of party if not above
How did you vote at the last general election? *
Are you a member of a political party? *
Are you, or have you ever been, politically active in any way e.g. held office, attended a political meeting, distributed leaflets, campaigned, stood as a candidate, worked for a political party, supported a campaign group? *
If yes, please specify (optional)
3. PRIVACY
During the casting process (and if you go on to become a contributor to the Programme), Mentorn Media and the commissioning broadcaster will process certain of your personal information for the purposes of considering your application for this Programme, to carry out reasonable background checks to verify the information you provide to us, for the purposes of producing the Programme, for our administration and related services, and where it is necessary in our legitimate interests to do so.

In addition, as part of our casting process (and as part of your contribution if you are selected to take part in the Programme), you are being asked above to provide certain details which are known as “special category personal information” and details of any past criminal convictions. Special category personal information is any information regarding racial or ethnic origin, political opinions, religious or philosophical beliefs, trade union membership, sexual orientation, genetic or biometric data.

Mentorn Media and the broadcaster will only process your ‘special category personal information’ with your explicit consent where you have given it below, unless it is required in order to comply with a particular legal obligation, such as to meet our safeguarding responsibilities.

Accordingly please confirm that you consent to the use of the special category personal information which you have provided by Mentorn Media and the broadcaster to consider your participation in the Programme and, if selected, to record your contribution (which may include some of your special category personal information) in order to produce the Programme:

 *
We will not keep your  contact information on file for the purpose of any future casting.

If you hear nothing from us, please assume that on this occasion your application has not been successful.

By filling out and returning this form, you are consenting to taking part in the casting process. Please note that by agreeing to be considered to participate in the Programme, you are also agreeing that we may share the information you supply to us with members of the production team and the commissioning broadcaster. For full details about how we use your personal information please read the Tinopolis group company privacy notice and the production specific privacy statement here: https://mentorn.tv/contributor-privacy-policy
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