Young Achievers Create Day Application Page

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.

Applicant details

Please fill out the details for each member of your family attending the activity.

Applicant one (VI child)

First name *

Last name *

Gender *

Male
Female
Other

If other, please explain how you would best describe yourself below

Date of birth *

Is the applicant *

Blind
Partially Sighted

Name of eye condition *

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

(1) Dietary information, including allergies *

Applicant two

2. First name *

2. Last name *

2. Gender *

Male
Female
Other

If other, please explain how you would best describe yourself below

2. Date of birth *

2. Is the applicant *

Blind
Partially Sighted
Not Visually Impaired

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 day *

2. Dietary information, including allergies *

Applicant three

3. First name

3. Last name

3. Gender

Male
Female
Other

If other, please explain how you would best describe yourself below

3. Date of birth

3. Is the applicant

Blind
Partially Sighted
Not visually 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 day

3. Dietary information, including allergies

Applicant four

4. First name

4. Last name

4. Gender

Male
Female
Other

If other, please explain how you would best describe yourself below

4. Date of birth

4. Is the applicant

Blind
Partially Sighted
Not visually 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 day

4. Dietary information, including allergies

Applicant five

5. First name

5. Last name

5. Gender

Male
Female
Other

If other, please explain how you would best describe yourself below

5. Date of birth

5. Is the applicant

Blind
Partially Sighted
Not visually 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 day

5. Dietary information, including allergies

Applicant six

6. First name

6. Last name

6. Gender

Male
Female
Other

If other, please explain how you would best describe yourself below

6. Date of birth

6. Is the applicant

Blind
Partially Sighted
Not visually 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 day

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.
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.
e. By signing this form I 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.
f. 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 £5 to attend this activity (under 5’s go free). If you are offered a place on this activity you will then be required to pay the full amount of £5 per person 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 activity. *

I agree

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

Please rate your VI child from 1-5 in the following areas (1 being the lowest and 5 being the highest):

Does your VI child regularly attend a youth club? *

Is your VI child a member of a social group outside of VICTA? *