Spring Family Weekend 2024 Form

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.

Please note, we can only accept a maximum group size of 6 of immediate family members, with a ratio of no higher than 3 adults per 1 child.

Applicant details

Please fill out the details for each member of your family attending the activity. Please name Applicant one as your VI child

Applicant one (VI child)

First name *

Last name *

Gender *

Male
Female
Other

If you have selected 'other', please outline below how you describe your child

Date of birth *

Is the applicant *

Blind
Partially Sighted

Is the applicant registered for their vision impairment? (We may ask for supporting evidence – see bottom of this form) *

Name of eye condition *

(1) Medical information (including allergies), other disabilities and/or additional information we may need to be aware of for the weekend *

(1) Dietary information, including allergies *

Applicant two

2. First name *

2. Last name *

2. Gender *

Male
Female
Other

2. If you have selected 'other', please outline below how you describe yourself

2. Date of birth *

2. Is the applicant *

Blind
Partially Sighted
Not Vision Impaired

Is the applicant registered for their vision impairment? (If applicable) (We may ask for supporting evidence – see bottom of this form)

Name of eye condition (if applicable)

2. Medical information (including allergies), other disabilities and/or additional information we may need to be aware of for the weekend *

2. Dietary information, including allergies *

Applicant three

3. First name

3. Last name

3. Gender

Male
Female
Other

3. If you have selected 'other', please outline below how you describe yourself

3. Date of birth

3. Is the applicant

Blind
Partially Sighted
Not Vision Impaired

Name of eye condition (if applicable)

3. Medical information (including allergies), other disabilities and/or additional information we may need to be aware of for the weekend

3. Dietary information, including allergies

Applicant four

4. First name

4. Last name

4. Gender

Male
Female
Other

4. If you have selected 'other', please outline below how you describe yourself

4. Date of birth

4. Is the applicant

Blind
Partially Sighted
Not Vision Impaired

Name of eye condition (if applicable)

4. Medical information (including allergies), other disabilities and/or additional information we may need to be aware of for the weekend

4. Dietary information, including allergies

Applicant five

5. First name

5. Last name

5. Gender

Male
Female
Other

5. If you have selected 'other', please outline below how you describe yourself

5. Date of birth

5. Is the applicant

Blind
Partially Sighted
Not Vision Impaired

Name of eye condition (if applicable)

5. Medical information (including allergies), other disabilities and/or additional information we may need to be aware of for the weekend

5. Dietary information, including allergies

Applicant six

6. First name

6. Last name

6. Gender

Male
Female
Other

6. If you have selected 'other', please outline below how you describe yourself

6. Date of birth

6. Is the applicant

Blind
Partially Sighted
Not Vision Impaired

Name of eye condition (if applicable)

6. Medical information (including allergies), other disabilities and/or additional information we may need to be aware of for the weekend

6. Dietary information, including allergies

Contact details

Name of parent/carer *

Email *

Home phone *

Mobile number *

Address 1 *

Address 2

City *

Post code *

Eye condition documentation

If this is the first VICTA activity that you are applying for, please note that applicants must be registered sight impaired or severely sight impaired, or be able to provide proof that they are registerable. Any information or documents supplied must include the applicant’s name, date of birth and visual acuity. *

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

Supporting documentation If the applicant is registered, please include a copy of one of the following registration documents: - Certificate of Vision 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

If you would like to upload any supporting documents such as a copy of your registration document, you can do so here. If supplying a CVI, please include Parts 1 & 2. If you are including a copy of a Blind Registration Card, please remember to include both sides. Only files saved as a jpeg or pdf formats will be accepted by the upload. Alternatively, you can email them to activities@victa.org.uk

Click or drag files to this area to upload. You can upload up to 5 files.

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? *

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

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 £85 per person to attend this activity. If you are offered a place on this activity you will then be required to pay a deposit of 50% of the full amount by 31/3/24 to secure your place. The remaining balance is due on 26/4/24. 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 activity. *

I agree

Have you referred another family to this Family Weekend who are new to VICTA? If so, please provide the family name below

If you have been referred to this Family Weekend by another family, please give their details below

Would you like to sign up for email updates from VICTA to hear about future activities? *

Yes please
No Thank you
I'm already signed up