Form

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

Parent/Guardian 2
If a second parent/guardian will be joining, please include their details below

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.

Photographs and filming

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.

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