Bodywhys | Media Panel Application Form

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Media & ResearchMedia Panel Application Form

Media Panel Application Form

Bodywhys Media Panel - Application Form

Information included in your application is kept confidential.

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Personal Details
Information included in your application is kept confidential
Name*
First Last
Address*
Street Address Address Line 2 Town/City County Postcode/Eircode Country
Email address*
Enter Email Confirm Email
Phone (mobile)*
Phone (landline)
Please contact me by...*
How did you hear about Bodywhys?

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I am...*
Gender
I am...*
Age

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Media work
I am...*
Who experienced the eating disorder?
Have you ever taken part in media work on eating disorders before?*
What sort of media work interests you?*
Select more than one, if you wish.
For broadcast - radio/podcasts and/or television I am comfortable with...*
Select more than one, if you wish.
My identity*
Please note, you can discuss any concerns with the journalist directly.

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Eating disorder experiences
My experience related to*
Type of eating disorder
At what age did you/your family member/friend first experience the eating disorder?*
For how long did you/your family member/your friend experience the disorder?*
Do you consider yourself/your family member/friend to be recovered/in recovery?*
Have you/your family member/friend experienced relapses?*
Did you/your family member/friend ever receive treatment for an eating disorder?*
Are you aware of why you/your family member/ friend developed an eating disorder?*

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Please give any additional information that you feel is relevant
Date of application*
DD slash MM slash YYYY
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Get in touch

Postal address

Bodywhys

PO Box 105, Blackrock, Co Dublin.

Office Admin phone: 01-2834963

Helpline service: 01-2107906

E-mail (Office): info@bodywhys.ie

E-mail Support Service: alex@bodywhys.ie

Registered Charity Number: 20034054 | CHY Number: 11961 | Company Number: 236310

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