Apply to earn your Bronze Duke of Edinburgh's Award with VICTA

Duke of Edinburgh's Bronze Award Application Form

Applicant details

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. If you are under 18 years of age this form must be completed and signed by a responsible adult who has permission to act upon your behalf, i.e. a parent or guardian.

First name

Last name

Gender

Male

Female

Date of birth

Participant's age

Participant's phone number

Participant's email

Address 1

Address 2

City

Postcode

Supporting parent/guardian

Parent/guardian full name

Relationship to participant

Parent/guardian address

Parent/guardian primary number

Parent/guardian secondary number

Parent/guardian email

Preferred contact

About you

Primary language

Please indicate your preferred reading format/communication mode (e.g. print including font size)

Are you currently registered blind or partially sighted?

Yes

Not registered

If you are not currently registered, would you describe yourself as:

Blind

Partially sighted

Name of eye condition?

Please list any other disabilities we should be aware of, how it affects you and others supporting you

Supporting documentation

If the applicant is registered, please include a copy of one of the following registration documents: - Certificate of Visual Impairment (CVI) - Blind Registration Card issued by local authority If the applicant is not registered, please provide: - a letter from an ophthalmologist confirming visual acuity. Please note, applications cannot be processed without these documents.

Uploading documents

Medical details

Name of doctor

Telephone number of doctor

Please list any other disabilities we should be aware of

Please give details of any additional difficulties such as bed wetting, problems with menstruation, emotional behaviour or medical conditions e.g. asthma, epilepsy, and any special aids or equipment which are used

Please describe how this affects you and how we should support you with these difficulties

Do you have any medical condition or recurring complaint of which we should be aware? (e.g travel sickness or diabetes). Please detail any medication we need to be aware of

Medication allergies

Food allergies

Dietary requirements (if none please indicate)

Independence skills

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

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:

Your personal independence

Your social skills

How you meet new challenges in a strange environment

Your level of self-esteem

Why did you choose to attend this activity

What are you hoping to gain from this activity

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. Do we have your permission to do so?

Yes

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 anaesthetics.

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.

Agreement to declaration

I agree

I do not agree

Do you give us consent to use your information for marketing purposes such informing you of future VICTA activities?

Yes

Signed (insert name)

Date

My relationship to the applicant (if applicable)

Parent

Legal guardian

Other

If 'other' please state

Agree to payment and T&C's

By checking this box you agree to pay £25.00 to enrol on the VICTA DofE Bronze Award Scheme. If you are offered a place on this programme you will then be required to make the payment to secure your place. By checking this box you also agree to our terms and understand that this payment is non refundable in the event of you withdrawing from the programme.