November Youth Break

Date: 6 to 9 November 2017
Venue: The Caldecotte Xperience, Milton Keynes
Age: 18 to 29 years
Cost: £40
Closing Date: 24 September 2017

The VICTA November youth break is now open to applicants aged 18 to 29 years old. This break will take place in Milton Keynes at the Caldecotte Xperience, a residential activity centre. The required contribution from participants towards the activity is £40.00 which includes food, accommodation and activities.

The Caldecotte Xperience offers a variety of exciting adventure activities and learning experiences for young people. The weekend should be action packed with activities such as sailing, canoeing, kayaking, windsurfing, climbing, high ropes, fencing and more.

As if that wasn’t enough excitement, we will also be heading off-site for a thrilling indoor skydiving experience at i-fly in Milton Keynes!

It is a chance to socialise with other people of a similar age group and share in new experiences whilst having fun. 

November Youth Break 2017 Application Form

Fields marked with a * are mandatory.


Note for applicants completing this form

After completion, if you have successfully submitted the form, you should receive a successful submission message. If you do not it may be because you have not completed a required field. Fields which have not been completed will then be marked with the message 'This is a required field' so you may wish to search this.

After your form has successfully gone through you will also receive notification via email. If you do not receive an email please contact the office on 01908 240 831 as there may have been a problem with your application.

Applicant Details

Contact Details

Emergency Contact (EC)

About You

Medical Details

Independence Skills

Applicant Details

The overall theme of this activity is about having fun, but we would like you to gain confidence and develop life skills through a programme of leisure, cultural and social activities. There may be times when you are expected to be fully independent and staff / volunteers will not be overseeing you (participants usually help each other at these times) e.g. moving between workshops or to the dining room. To help us plan our activities and staffing levels please describe your ability in the following areas:

In order to ensure that activities are adequately staffed we need full and accurate information about all participants. Please note we reserve the right to refuse admission to the activity or ask a participant to leave the activity if the information given proves inaccurate or the conduct of the participant reaches an unacceptable level.

Photographs and Filming

Photographs and video footage may be taken during our activities. These will be used to create photo albums both on our website and on social media after the activity to share with family and friends and to promote the activity. VICTA may also use any photographs or video material taken during an event for the future marketing, publicity and fundraising of activities.

Declaration, privacy and consent

To be signed by the applicant or a responsible person.

This form has been completed accurately and I undertake to update VICTA should any of the information in this form change.

a. I agree to take part in VICTA's activity and have read all the information sent to me.

b. I acknowledge the need to behave responsibly at all times during the activity.

c. I confirm that this form has been completed accurately and I undertake to update VICTA's organisers should any information contained on the form or personal circumstances change.

d. In the event of an emergency/accident, I consent to emergency medical treatment, which may include the use of anesthetics.

By signing this form you consent to VICTA using the information supplied for the purpose of administering the named event. All the information will be treated in the strictest of confidence and made available only to those staff working with the participant. Contact information will be retained and used for marketing of other relevant services.

I give consent for VICTA to carry out the following in accordance with the Data Protection Act (1998) and to store my personal information on VICTA's database and/or any other suitable system.

I agree to provide any relevant additional information such as my CVI with my application.

Once you have a place on the activity, you will be informed by email along with the other successful applicants. It is normal practice for us to CC all applicants so that you can all see who is attending and make contact if wished before the activity. If you do not wish us to share your email address with others on the email please tick the box below.

Agree to payment and T&C's

Cheques must be made payable to VICTA and posted to:
VICTA
5 Douglas House
32-34 Simpson Road
Fenny Stratford
Milton Keynes
MK1 1BA

If you wish to pay by card over the phone please call us on 01908 240831.