Form - VICTA

Apply for the Camden Roundhouse session

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.

Applicant details

First name *

Last name *

Gender *

Male
Female
Other

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

Date of birth *

Would you describe yourself as blind/partially sighted? *

Blind
Partially Sighted

Do you have a guide dog? *

Contact details

Email *

Phone (please provide us with the most convenient number to contact the activity applicant on) *

Address 1 *

Address 2

City *

Post code *

Emergency contact (EC)

EC full name *

Relationship to participant *

EC address *

EC primary number *

EC secondary number

EC email

Medical details

Medical information (including allergies), other disabilities and/or additional information we need to be aware of for the duration of this activity. Please also detail any medication taken we need to be aware of (please note that all participants must be able to administer their own medication independently and VICTA staff and volunteers can not support with this). *

Dietary information including any allergies. Please ensure this is as accurate as possible as this information is used to inform catering teams. *

Independence skills and general information

Please indicate your level of independence in the following areas by selecting your response and giving details if the assistance is required.

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.

Your personal independence

Use of toilet *

Independently
With some assistance

If assistance is required please give details

Mobility *

Independently
With some assistance

If assistance is required, please give details, what distances are manageable?

Your social skills

Anything else we should know about you?

Why did you choose to attend this activity?

Eye condition

Name of eye condition? *

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.

Confirmation of vision impairment *

I confirm I am/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 Visual 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 (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 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 may be used on both VICTA and the Roundhouse's websites, on both VICTA and the Roundhouses's social media channels and to help promote the activity. VICTA and The Roundhouse may also use any photographs or video material taken during an event for the future marketing, publicity and fundraising of activities. There may also be press present on the day and photographs and videos may be used by the wider press to promote NaviLens and the session. 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 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 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.
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? *

Applicants must be aged 18 to 25 years *

I confirm that I/the applicant will be 18 to 25 years old at the time of this activity

Signed (insert name) *

Date *

My relationship to the applicant (if applicable)

Parent
Legal guardian
Other

If 'other' please state