VICTA Science Fair Hot Wheels Braille Racer - Application

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Hot Wheels Braille Racers

Applicant details

First name of VI child/young person *

Surname of VI child/young person *

Date of birth *

Parent/Guardian contact details

Parent/guardian first name *

Parent/guardian surname *

Email *

Address one *

Address two

City *

County *

Post code *

Phone number *

Vision impairment information

To qualify for a free Hot Wheels Braille Racer, applicants must be registered sight impaired or severely sight impaired, or be able to provide proof that they are registerable. Any information supplied must include the applicant’s name, date of birth and visual acuity.

Confirmation of vision impairment *

I confirm the applicant is registered or registerable Sight Impaired or Severely Sight Impaired

Declaration, privacy and consent

By completing this form you consent to VICTA using the information supplied for the purpose of administering this offer. All the information will be treated in the strictest of confidence and made available only to those staff working on this project. 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 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 *

I agree
I do not agree

Do you/your child already have an interest in STEM? *

Yes
No

Do you/your child actively engage in STEM subjects? *

Yes
No

Would you like to receive emails updates from VICTA regarding our activities and services? *

Yes
No
I'm already signed up

Signed (insert name) *

Date *

My relationship to the applicant *

Parent
Legal guardian
Other

If 'other' please state

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