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Tell your story

You could help to raise awareness of breast cancer by sharing your story with the media. Real-life stories such as yours are vital in inspiring others and encouraging people to support Breakthrough Breast Cancer. We will always make sure you are happy to take part in any media interviews and we will never pass on your details without your consent.

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denotes mandatory fields.

Personal Details

Name

Address

Male/Female

Phone number (day)

Phone Number (evening)

Date of Birth

Occupation

Preferred method of contact

It can help us if we have a photo of you to accompany your story

(allowed formats: jpg, png, gif, bmp)

Your Family

1. Do you have any children?

2. Children's date of birth

3. Do you have any grandchildren?

4. Grandchildren's date of birth

Your Experience

5. Have you had breast cancer?

6. What age were you when diagnosed?

7. What year were you diagnosed? (approximately)

8. Please tick any of the below that applied to your breast cancer diagnosis:

I noticed a change to my breast My partner noticed a change to my breast I was diagnosed through the NHS Breast Screening Programme My breast changed in size or shape There was a change to my skin texture There was a change in appearance of my nipple There was discharge from my nipple There was a rash on my breasts There was a lump in my breast or armpit

Other-please specify

9. What stage was your breast cancer?

Other - please specify

11. Do you have a family member or friend who has been affected by breast cancer?

12. Have you or any members of your family had genetic testing?

Your Story

13. Whether you, a friend or a member of your family has had breast cancer, please use the below box to tell us as much as you can about your experiences. You may want to tell us about how things have changed for you, talk about the support you recieved, or tell us about any significant achievements or extraordinary experiences that you have had. Please feel free to write as much or as little as you feel comfortable with.

14. Do you have any other involvement with Breakthrough Breast Cancer?

Other - please specify

I agree to Breakthrough Breast Cancer keeping and using this information for the purpose of promoting Breakthrough and the cause of breast cancer through the media and other relating occasions. I understand Breakthrough will not give out my details without my verbal and/or written consent on each occasion (Data Protection Act 1998)*

Yes No

Once you have submitted your form, you will have registered interest to be a Breakthrough Breast Cancer media volunteer. By telling your story, you can help Breakthrough to raise awareness of breast cancer and the issues surrounding the disease. Sharing your experiences can encourage others to be breast aware and inspire people to support Breakthrough Breast Cancer.

Once your form has been submitted a member of the Breakthrough Media Relations team will be in touch.

Thank you for your support.