SUFC Sign-Up Form (Editable Participant Version)
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Transcript of SUFC Sign-Up Form (Editable Participant Version)
8/22/2019 SUFC Sign-Up Form (Editable Participant Version)
http://slidepdf.com/reader/full/sufc-sign-up-form-editable-participant-version 1/8
National CitizenService (NCS) 2013
APPLICATION
FORM• Open to Year 11 & 12 Students
• Limited places available
ncsflt
IT allSTARTS
with
YES
8/22/2019 SUFC Sign-Up Form (Editable Participant Version)
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First Name:
PARTICIPANT’S DETAILS
County:
Home Tel No:
Email:
Twitter:
Date of Birth: (DD/MM/YYYY)
First Name:
PARENT OR GUARDIAN DETAILS
Home Tel No:
Email:
Twitter:
How did the Participant hear about NCS? (Please tick all that apply)
School / College
Advert
Media Article / Programme
Facebook / Twitter / Social Media
Other, please explain:
What was the last School / College the Participant attended, or is still attending?
School / College Name:
School / College Address & Postcode:
Mainstream Secondary School or College
Faith Secondary School or College
Special School
Pupil Referral Unit (PRU)
Full Address:
Surname:
Postcode:
Town/City:
Mobile Tel No:
Facebook:
Gender: (Please tick one) Male Female Prefer not to say
Age:
Surname:
Mobile Tel No:
Facebook:
Word of Mouth
My parent / guardian
Through a Youth Group / Organisation
TV / Radio / Newspaper
Independent School or College
Not at School
Educated at home
Prefer not to say
To be completed by or on behalf of the Participant. It should be checked thoroughly and signed
by a duly authorised parent, guardian or carer (“The Signatory”). PLEASE PRINT IN BLOCK CAPITALS
Matthew Dennis
35 Meadowhead
Sheffield
SYK S8 7UB
0114 274 5154 0792 344 2986
[email protected] facebook.com/mcmattd
twitter.com/matt_dennis_
17/12/1996 16
Franceska Dennis
0114 274 5154 0792 344 2986
N/A
Notre Dame High
s10 3bt
8/22/2019 SUFC Sign-Up Form (Editable Participant Version)
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What is the Participant currently doing? (Please tick all that apply)
What best describes the Participant’s ethnic background? (Please tick one)
What is the Participant’s faith / religion? (Please tick one)
Does the Participant have any disabilities? (Please tick one)
Apprenticeship
Traveller of Irish heritage
Hindu
Studying for other qualification
Irish
Buddhist
Study AS / A-levels
White British
Christian
(A disability is something that can be physical or mental and affects day to day life. It can take many forms)
Yes No Prefer not to say
Voluntary work
Gypsy / Roma
Sikh
Stayed at home for another reason
Any other white background
Muslim
Paid work (full-time or part-time)
Indian
Pakistani
Bangladeshi
Any other Asian background
Chinese
Don’t know
Black African
None
Studying for GCSE’s
White and Black Caribbean
Other
Looking after the home or family
Black Caribbean
Jewish
None of these
White and Black African
Don’t know
Prefer not to say
White and Asian
Prefer not to say
Any other Mixed background
Any other Black background
Any other ethnic group
None of these
Prefer not to say
8/22/2019 SUFC Sign-Up Form (Editable Participant Version)
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If you have answered yes to any of the above, please give more details:
If yes, which of the following describes the Participant’s disability? (Please tick all that apply)
Volunteering: has the Participant previously helped out or volunteered with alocal group, project or organisation? (Please tick one)
Does the Participant face any specific issues or barriers to participating
in activities? (Please tick all that apply)
Deaf or hearing impaired
Blind or partially sighted
Yes, they have regularly helped out or volunteered
History of offending
In or recently in care
Young carer
Specific learning difficulty (eg dyslexia)
Yes, they have tried helping out or volunteered
Difficulty with numeracy or literacy
History of truancy
Rurally isolated
Autistic Spectrum Disorder / Asperger Syndrome
Unseen disability (eg diabetes, epilepsy, heart condition)
Mental health difficulties
Teenage parent (including pregnant)
A statement of special educational needs
Prefer not to say
Wheelchair user or mobility difficulties
No, they haven’t helped or volunteered
Substance mis-use
Does not face any difficulties
Other, please state
Disability, special need or medical condition not listed here
8/22/2019 SUFC Sign-Up Form (Editable Participant Version)
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DISCLAIMER AND MEDICAL STATEMENT (Please tick the relevant box, providing further information if required)
CONSENT FOR WATER RELATED ACTIVITIES
TRAVEL AND COLLECTION STATEMENT
Please tick here to give consent for your son/daughter to participate in ‘water related activities’
Please tick here to accept the Travel and Collection Statement
Please tick here to confirm you accept our Disclaimer and Medical Statement
Does the Participant have any injuries, weaknesses, medical conditions, recurrent illnessesor allergies which may affect, or be affected by, exercise or physical contact?
Is the Participant taking any medicine or undergoing any treatment that needs to becontinued during the programme?
Is the Participant known to be allergic or sensitive to anything (eg penicillin, aspirin orfood types)?
Is there any other medical information relating to the Participant that the NCS staffshould be aware of?
Does the Participant have any specific dietary requirements?
During NCS your son/daughter may get to take part in ‘water related activities’ which may include but are not limited to swimming, kayaking,
canoeing and rafting. While this list is not exhaustive please indicate below if you are happy for your son/daughter to take part in such activities.
PLEASE NOTE:
• During the programme the Participant will be responsible for getting to and from agreed venues, and will be allowed to leave without collection.
• For the residential venues or where transport facilities are provided as part of the project, the Participant will be responsible for
getting to and from the designated meeting location. Participants will not be allowed to leave other than from that location, but will
be permitted to leave from that location without collection.
• During the activities, for example as part of the Social Action Project, the Participant may be required to undertake travel
unsupervised, either on foot or by public transport.
You give us permission to allow the Participant to leave designated locations (other than the residential or supervised trips) without
collection, and to undertake some travel unsupervised
If you have answered yes to any of the above questions, please state the issue and any action or medication required and / or
activity in which the Participant can not be involved:
PLEASE NOTE:
• Staff are not permitted to take responsibility for or to administer medicines. You are therefore responsible for ensuring any medicine
is available and taken correctly.
• You understand that whilst involved in the programme activities the Participant will be under the care of the community trust staff
and other suitably approved adults. Whilst we will take all reasonable care of Participants you acknowledge that in the absence of
our negligence, participation in the programme is at your sole risk and that we shall not be liable for damage or injury arising from
activities
In the unlikely event of an accident occurring, you provide your permission for a designated representative of the community trust to
authorise emergency medical treatment, including the use of anaesthetic if deemed necessary.
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
8/22/2019 SUFC Sign-Up Form (Editable Participant Version)
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PHOTOGRAPHS
Please tick here if you do not wish for your son/daughter to be included in photographs for promotional purposes
In case of an emergency, who should we contact?
Name:
Relationship to Participant: (eg parent, neighbour or other)
Additional Contact Name:
Relationship to Participant:
To receive further information about The United Initiative and related activities or
Sheffield United Football Club please provide a mobile number and / or email address:
Mobile: Email:
Contact Numbers
Contact Numbers
H:
H:
M:
M:
W:
W:
Address:
Address:
PLEASE NOTE:
• During the course of NCS, activities may be recorded through photographs and video film both for the Participants to collate and celebrate
their experiences but also for evaluation and promotional purposes by the community trust, The Football League Trust, the Cabinet Office
and partner agencies.
You agree that the images may be used in media or publicity materials and celebration publications produced by those agencies.
You understand that these images may be safely stored or archived digitally or manually and may be publicised in a variety of media forms
including managed social network sites.
EMERGENCY CONTACT DETAILS
FURTHER INFORMATION
CONTRIBUTIONS
PAYMENT METHOD
The standard price of NCS is £50, as a contribution towards the entire costs. Financial support to cover this £50 may be available if
required (for example if your son/daughter is entitled to free school meals). Please contact your local NCS Coordinator for information.
£25 refundable on completion of the project.
We request that contributions are made by cheque, payable to THE UNITED INITIATIVE.
Upon receiving the completed form, your NCS Coordinator will be in contact regarding payment.
Franceska Dennis
Mother
0114 274 5154 0792 344 2986
35 Meadowhead
8/22/2019 SUFC Sign-Up Form (Editable Participant Version)
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ACCEPTANCE STATEMENT
1. I confirm that I have read and understood the Terms and Conditions overleaf, that all relevant information about theParticipant is correct and that I accept on behalf of myself and the Participant all such conditions. Please tick box
2. I acknowledge the need for acceptable responsible behaviour on the Participant’s part, and have received a copy of theCode of Conduct. Please tick box
3. I have read and accept the NCS Privacy Policy – section 10 of the Terms and Conditions. Please tick box
4. I agree that the Participant’s email address can be shared with the Cabinet Office so that he/she can be kept informedabout further opportunities and offers available to him/her as an NCS Participant. Please tick box
5. I confirm I have full authority to sign on behalf of the Participant. Please tick box
Name of Signatory (BLOCK CAPITALS):
Relationship to Participant (eg parent, guardian, carer):
Address (if different to Participant’s details):
Signature: Date:
Return completed form to:
NCS
United initiative
c/o sufc
bramall lane
sheffield
s2 4su
Queries: 0114 292 2347 or [email protected]
website: sufc-community.com
ONCE COMPLETED WE RECOMMEND THAT YOU TAKE A COPY OF THIS FORM FOR YOUR OWN RECORDS
PLEASE DO NOT WRITE IN THIS SECTION
ADMINISTRATOR USE ONLY
Actual Date of Sign Up:
Date entered on to system:
School ID:
Spring
Summer
Autumn
IF SUBMITTING THIS FORM ELECTRONICALLY,
TYPING THE NAME IN THE SIGNATURE BOX
WILL COUNT AS ACCEPTANCE OF THE TERMS
FRANCESKA DENNIS
Mother
FRANCESKA DENNIS 21.06.2013
8/22/2019 SUFC Sign-Up Form (Editable Participant Version)
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1. INFORMATION ABOUT US
1.1. References in these Terms and Conditions to “we” or “us”are references to The United Initiative.
1.2. You can contact us if you have queries in relation to yourBooking or for any other reason on the number provided.
2. YOUR BOOKING
2.1. By filling out and signing the Booking Form you aresubmitting a request to book a place on the NationalCitizen Service programme with The United Initiative. Allrequests are subject to acceptance on confirmation of thebooking and that payment has been received.
3. IF YOU HAVE TO CANCEL YOUR BOOKING
3.1 To cancel your booking please contact us via email,phone or post explaining that you would like to cancel. Insome circumstances refunds may be issued but this willbe at our discretion.
4. OUR STAFF
4.1. The Football League Trust and The United Initiative arecommitted to safeguarding and promoting the welfare ofyoung people and expects all staff, volunteers, parents,partner agencies and commissioned services to sharethis commitment.
4.2. We confirm that all our delivery staff have been subjectto Enhanced Criminal Records Bureau (CRB) checks andhold suitable coaching and first aid qualifications.
5. LIABILITY
5.1. The booking form contains certain information anddisclaimers which, by signing the form, you accept that inthe absence of any negligence on our part, participationin the National Citizen Service programme is at your ownrisk.
5.2. We have public liability insurance cover of at least £5million.
5.3. We do not accept liability for loss or theft of personalbelongings that occurs while on the programme. If yourson/daughter brings valuables with them this will be atyour risk.
6. COMPLAINTS
6.1. We are committed to ensuring your son/daughter has agreat experience but if you or your son/daughter are not
entirely happy with their experience please contact theNCS Co-ordinator in the first instance. If your complainthas not been resolved to your satisfaction please contactus using the contact details provided, with full details ofthe complaint and we will attempt to resolve it as quicklyas possible.
7. MEDICAL / DIETARY / OTHER REQUIREMENTS
7.1. If any child included on your Booking (a) has specificdietary requirements; (b) is taking medication; (c) hasallergies; and/or (d) has any special needs that willaffect his or her participation in the programme it isyour responsibility to inform us of this and provide allnecessary details about this at the time of Booking.
7.2. Please note that our staff are not permitted to take
responsibility for or to administer medicines and thereforeyou are responsible for ensuring any medicine is availableand taken correctly.
7.3. We will maintain a register of the Participants attendingthe programme. Please note that Participants will beable to leave the non-residential elements without thepermission of parent / guardian.
8. DISCIPLINE
8.1. Participants on the programme will be treated withrespect and must treat others including staff and other
Participants with respect. We reserve the right to refuseto allow your son/daughter to continue attending theprogramme if our staff deems their behaviour to beunacceptable.
8.2. We have a Code of Conduct to which Participants shouldadhere, a copy of which is supplied in the informationpack.
9. DATA PROTECTION
9.1. When you make a booking we will collect and processthe personal information you provide in order to providethe services you have requested and for other specificpurposes subject to your consent.
10. PRIVACY POLICY
10.1 By ticking section 3 of the Acceptance Statement ofthis sign up form, you agree to your personal databeing stored, shared and used by the Cabinet Officeand the following organisations: any independent bodycommissioned by the government to run NCS, NCSproviders, other government bodies, strategic partnersof NCS or other organisations (including organisationsrunning all or part of NCS in the future).
For the purposes of:
• Contacting you about your son/daughter taking part inNCS.
• Contacting you about taking part in press andcommunications activity relating to NCS.
• Helping us develop, deliver, and improve our service,content and advertising.
• Internal purposes such as auditing, evaluation, dataanalysis, preventing or detecting fraud or error,and research to improve our service and customercommunications.
11. IMAGES
11.1. During the course of NCS, activities may be recordedthrough photographs and video film both for theParticipants to collate and celebrate their experiencesbut also for evaluation and promotional purposes by thecommunity trust, The Football League Trust, the CabinetOffice and partner agencies.
11.2. I agree that the images may be used in media orpublicity materials and celebration publications producedby those agencies. These images may be safely stored orarchived digitally or manually and may be publicised in avariety of media forms including managed social networksites.
11.3. If you do not wish for your son/daughter to be includedin photographs and video materials for promotionalpurposes, you are required to clearly indicate this on theconsent form.
12. GENERAL
12.1. The Booking Form, these Terms and the Disclaimerset out the whole of the Agreement between you andus in relation to the subject matter of this Agreement
and supersede any prior agreement, understanding orarrangement between us about such subject matterwhether oral or in writing.
12.2. This Agreement shall be exclusively governed by andconstrued in accordance with the laws of England andWales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales.
NATIONAL CITIZEN SERVICE TERMS AND CONDITIONS