Temporary form Early Years workshop

Parent/Guardian 1

First name *

Last name *

Email *

Address line 1 *

Address line 2

City *

Post code *

Contact phone number *

Is the applicant *

Blind
Partially Sighted
Not vision impaired

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 vision impaired

Are you currently a member of the VICTA Parent Network Facebook group? *

Yes
No

Do you currently have a Sensory Discovery Pack? *

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 vision impairment? *

Yes
No

to also the

Name of child's eye condition? *

Supporting documentation

If your child is registered for their visual impairment, please include a copy of one of the following registration documents: - Certificate of Visual Impairment (CVI) - Blind Registration Card issued by local authority - Letter from the local council confirming the person to be registered 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 (please supply a jpg or pdf). 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 parents@victa.org.uk

Click or drag files to this area to upload. You can upload up to 3 files.

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 VICTA/Guide Dogs' social media after the activity to share with family and friends and to promote the activity. VICTA and Guide Dogs 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? *

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

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