EmailMe Form - NCS Sign Up Form

Participant Details

Did Someone Refer You?

If you have been recommended by a friend please put their name here

Resident Confirmation *

I confirm that I have read the statement below:

Inspire Guide Change is a provider of the NCS programme in Cambridgeshire and must have access to Cambridge for weeks 3 & 4.

Name *

First Last

D.O.B *

DD / MM / YYYY

Multiple Choice *

Male

Female

Rather not say.

Jumper/T-Shirt Size

Address

Street Address City State / Province / Region Postal / Zip Code

Day Contact Number *

Evening Contact Number *

Email

Please indicate which NCS course you would prefer to attend: *

Summer 2017 (Starting 17th July) 4 week programme

Summer 2017 (Starting 24th July) 4 week programme

Cadet Programme 2017

Autumn 2017 (Starting 20th Oct) 1 week + 30hrs

Spring 2018 (Starting 9th Feb) 1 week + 30hrs)

Ethnicity.... Please select *

Friend Referral - If you would like to complete the programme with a friend then please put their details below:

	Name	Contact Number
Name of Friend 1
Name of Friend 2
Name of Friend 3

Parent/Guardian First Name *

First Last

Relationship to participant *

Parent/Guardian Address

Street Address City State / Province / Region Postal / Zip Code

If different from previous address provided for the participant

Day Contact Number *

Evening Contact Number *

Email

Second emergency contact

Second emergency contact *

First Last

Relationship to participant *

Second Emergency Address

Street Address City State / Province / Region Postal / Zip Code

If different from previous addresses provided

Day Contact Number *

Evening Contact Number *

Medical Contact Details

Doctors Name: *

Doctors Phone *

Doctors Address *

Street Address City State / Province / Region Postal / Zip Code

Authorisation is given for NCS staff to administer First Aid and/or transfer my young person to
hospital should an emergency arise: *

Yes

No

NCS includes new environments and challenges. Please help us keep your child safe and happy by
answering the questions below. My child:

Has special educational needs

Requires a same-gender group

Is in care or has recently left care

Requires access to prayer facilities

Other

Requires other special considerations (please specify above):

Please provide specific details regarding your child safety and happiness.

My child can swim 50 metres *

Yes

No

Please note your child does not have to be a competent swimmer to take part in NCS

Name of the school/college my child attends: *

Participation in the NCS programme involves physical activities and learning out in the local
community with businesses and the public. If your child has any medical conditions which could limit
their ability to participate in any of these activities (or are currently taking any medication
for any condition or illness) please provide full details below:

Wheelchair user or mobility difficulties

Mental health difficulties

Blind or partially sighted

Deaf or hearing impediment

Autistic Spectrum Disorder / Asperger Syndrome

Disability, special need or medical condition not listed above

Special dietary requirement or food allergy

Other

You must declare all information - it will not stop your child from gaining a place but will allow us to
keep them safe.

Please enter details of any other medical conditions, dietary requirements or allergies here:

Please provide specific details on any medical conditions or dietary requirement.

Medical Permission – please tick the appropriate box *

My child can administer their own medication

My child will need assistance to administer their medication

Not applicable

Medical support at residential/camping events In the event of your child suffering from a common ailment would you agree to the following medications being offered to your child? *

Contributions

The total cost of the NCS programme and residential is over £1,000. We ask parents/guardians to contribute £50 for courses towards this cost. There is no payment required if your child is entitled to Free School Meals, or was entitled when in secondary school.

Contribution Options *

I agree that a contribution of £50 is required to secure my child’s NCS experience (This can be a £5 deposit followed by £45 at leave two months before you preferred start date)

I am exempt from payment as my child is entitled to Free School Meals

Payment Options

PayPal (Follow instruction after the form has been submitted)

By Phone (Please call 0844 4480 159) *Please allow 48hrs for us to process your form

Cheque (Payable to Inspire Guide Change)

Bank Transfer: Sort Code: 09-01-28 Acc No: 55244999

Please send cheques to PO BoX 316, Ely, CB7 9FS

Bursaries

Bursaries can be accessed in some cases to cover the cost of the contribution and the costs of accessing the programme e.g. if your child requires appropriate clothing to take part in outdoor activities. In particular, we will consider bursary applications from participants who are teen parents, not living with their parents, have caring responsibilities or those who do not have a parent/guardian who works.

Please tick here if you would like to apply for a bursary

Tick Here

No refund policy

No refunds are available for cancellations or non-attendance, unless under exceptional circumstances.

Confirmation *

Yes I have read the 'no refund' policy and understand that refunds are not available for cancellations or non-attendance

Publicity and Media Statement

Throughout NCS participants take part in activities that support their personal development and promote community engagement. Occasionally staff, media and young people themselves record these activities using photographs or video. This content may be used to promote or champion the good work of NCS and its participants via newspapers, websites, social networks or other suitable promotional media. By taking part in NCS and not informing us otherwise, we assume both NCS participants and their parents/guardians accept that their image, video and comments may be used in public print, web use, display or broadcast. Any photos or videos used will be positive, and we are happy to share with you any media published. All images and footage is kept securely and will not be used for any other purposes than those stated above.

Please tick that you have read, understood and accept the Publicity and Media Statement

Agree

Code of Conduct

By completing and signing this application form both parent and applicant agree to the rules below: • NCS participants are expected to take part in all programmed activities. • Participants are not allowed to leave the residential or other site without permission from their Group Leader. • Participants are expected to follow any emergency procedure, such as a fire drill, as directed by their Team Leader or other staff involved in the NCS programme. • Participants are not allowed in other people’s rooms or tents. • There is a no alcohol policy throughout all elements of the NCS programme. • The possession, sale, purchase or use of any illegal substances is strictly forbidden. • NCS participants should not involve themselves in dangerous activities that will cause injury to themselves, other NCS participants or staff. • No one should engage in abusive or anti-social behaviour towards other participants or staff.

Please tick that you have read, understood and accept the Code of Conduct Statement *

Agree

Personal Belongings Statement

I understand that each young person on the NCS remains responsible for their own property, clothing, and valuables and that neither the NCS Provider or Reed in Partnership Limited shall be held responsible for any loss, damage, or destruction which occurs to any such property, clothing, or valuables during the course of this programme.

Please tick that you have read, understood and accepted the Personal Belongings Statement *

Agree

Travel and Collections Statement

It is the responsibility of the NCS Participant to travel to and from meeting points where transport has been pre-arranged and to travel directly to and from agreed venues where transport is not pre-arranged. Where transport has not been prearranged NCS Participants will be allowed to leave venues without collection and during the course of the activities NCS Participants may be required to undertake travel unsupervised, either by foot or by public transport.

Please tick that you have read, understood and accepted the Travel and Collections Statement *

Agree

Information Update Statement

I will advise the NCS Staff, in writing, of any changes to information on this form prior to starting NCS.

Privacy Policy

The information you have provided will be held on computerised and paper-based systems that you may access under the terms of the Data Protection Acts of 1984 and 1988. By agreeing to us storing your name and contact information, you are agreeing for it to be shared and used by the Cabinet Office, NCS contractors and their sub contractors, NCS strategic partners, fraud detection agencies, and other organisations that support the delivery of NCS now or in the future. The information you give us may be used to contact you about your NCS application, graduate opportunities, events, research, promotions, competitions, and press and communications activity related to NCS. Our full privacy policy can be viewed at www.ncseast.co.uk/privacy. You can withdraw your consent by contacting ncs.east@reed.co.uk.

Attendance Policy

NCS has a limited amount of places. Each NCS place receives funding of over £1000 from the government. If young people give up their place close to the start of programme the place can be very difficult to re-fill, meaning wasted government funds and wasted opportunities for young people. Please help us by agreeing to the pledge below:

I will do everything I can to ensure I am able to fully complete my NCS Programme. If I cannot take part I will let my NCS provider know at least one month in advance.

Permission

By signing below, you have read and accepted all of the above statements.

Young Person's Name *

Date Time *

DD / MM / YYYY

Authorising Parent/Guardian Name *

Date Time *

DD / MM / YYYY

	Yes	No
Paracetamol
Piriton/Chlorophenamine (to address allergies)
Ibuprofen