Level 3 Environmental Leadership Programme

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. 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.

Confirmation of vision impairment

To qualify for this activity the lead applicant (your VI child) must be either registered or registerable as blind or partially sighted (sight impaired/severely sight impaired). VICTA will ask for supporting evidence post application if we have not previously received it.

Independence skills

Please indicate your level of independence in the following areas by selecting your response and giving details if the assistance is required.

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.

General information

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. To help us plan our activities and staffing levels please describe your ability in the following areas:

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/for my child to take part in VICTA's activity and have read all the information sent to me.
b. I acknowledge the need to/for my child 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 anaesthetics.
e. 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.
f. Whatsapp is a great tool that can be used to communicate activity information and help facilitate social interactions. From time to time, VICTA facilitates Whatsapp groups for 18+ participants who have given consent to do so to get to know one another before an activity. While VICTA facilitates these opportunities, they are not monitored and therefore your behaviour and language used on Whatsapp must match the expectations we have of you when we meet in person – polite, courteous, and inclusive at all times. If you have any questions surrounding this, please contact the Activities Team on [email protected]
g. 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. We may need to share your details with third party suppliers in relation to this activity. Contact information will be retained and used for marketing of other relevant services.
h. I give consent for VICTA to carry out the following in accordance with the UK General Data Protection Regulations as supplemented by the Data Protection Act 2018 and related laws and to store my personal information on VICTA's database and/or any other suitable system.