Free Junior Partially Sighted Football Taster Session - Liverpool

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.

Applicant details

First name *

Last name *

Gender *

Male
Female
Other

If you have selected other, how do you currently describe yourself?

Age at time of activity *

Address 1 *

Address 2

City *

Post code *

County *

Main contact name (if the applicant is under 18 please provide a parent/guardian contact name) *

Phone: please provide us with the most convenient number to contact the activity applicant on. (If the applicant is under 18 please provide a parent/guardian contact number) *

Email (if the applicant is under 18 please provide a parent/guardian contact email adddress) *

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.

name) contact contact

Please confirm that the applicant is registered or registerable as Sight Impaired or Severely Sight Impaired *

Sight Impaired
Severely Sight Impaired

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 celebrate the event, this may include your child’s name and age. VICTA may also use any photographs and/or video material taken during an event for marketing purposes, including being displayed on the VICTA websites, on our social media channels, on charity emails and by connected third parties working in partnership with VICTA on this event/activity. Do we have your permission? *

Yes
No

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/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.

Agreement to declaration *