Email Apply for the online Cerebral Visual Impairment (CVI) session for parents (mainstream education) 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. If you are having difficulty with the form, please contact the office on 01908 240 831. Applicant details Please fill out the details for each parent/carer/guardian attending the activity (at the same address, using the same dial-in). Parent/Guardian 1 First name * Last name * Email * Address 1 * Address 2 City * Post code * Contact phone number * Is the applicant * Blind Partially sighted Not visually impaired Are you currently a member of the VICTA Parent Network Facebook group? * Yes No Parent/Guardian 2 If a second parent/guardian will be joining, please include their details below First name Last name Is the applicant Blind Partially sighted Not visually impaired Are you currently a member of the VICTA Parent Network Facebook group? * Yes No Details of your VI child Please fill out the details for your child who has a visual impairment, although children are not attending this is required for our information and planning. Child's first name * Child's last name * Child's date of birth * Is your child * Blind Partially sighted Is your child registered for their visual impairment? * Yes No Name of child's eye condition? * If you have a question ready that you would like to ask the workshop providers, please include it here Photographs and filming Photographs and video footage may be taken during our online 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 No Declaration, privacy and consent To be signed by the applicant. 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 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. 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. 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 Signed (insert name) * Date * My relationship to the applicant (if applicable) Parent Legal guardian Other If 'other' please state How did you hear about this activity? * Web search VICTA email Referral from a professional Referral from another charity Word of mouth Social media At an exhibition or conference Other Would you like to be added to the VICTA email database to be kept up-to-date with charity news and new activities? * Yes No I'm already signed up
