Cherwell DC Bodicote House Active Leader Course 12-16 August 2024 Student Registration

Cherwell District Council

Active Leader Course 12-16 August 2024 at Bodicote House

Registration Form

Please complete this registration form carefully, ensuring your name and date of birth are correctly provided. Your name should be as you wish it to appear on your end of course Award certificate.

The Active Leader course will take place from Monday 12^th to Friday 16^th August 2024 at Cherwell District Council, Bodicote House, Bodicote, Banbury OX15 4AA. 9.30am – 3pm each day. On the first day please go to reception to meet your course trainers. There is visitor parking available. Please note that part of the course will take place across the road on the field/village hall with the full supervision of the trainers at all times. Please wear appropriate clothing and shoes to be active during the course.

Course Code *

Student First Name *

Student Last Name *

Student Date of Birth *

Student Email Address *Not school email

Student Phone *Preferably Mobile Phone Number

Student Home Address *

Address Line 2

City *

County *

Post Code *

Name of School *

Year Group *Scroll down for more options

Tee Shirt Size *

Parent/Guardian/Carer Name *

Parent/Guardian/Carer Email Address *

Parent/Guardian/Carer Phone *Preferably Mobile Phone Number

Emergency 1 Contact Name *

Emergency 1 Contact Phone *Preferably Mobile Phone Number

Emergency 1 Contact relationship to Student

Emergency 2 Contact Name *

Emergency 2 Contact Phone *Preferably Mobile Phone Number

Emergency 2 Contact relationship to Student

Access Requirements? *Please select 'Yes' if there is any important access information that we should be aware of, eg Wheelchair, hearing, sight, special learning needs (ADHD, Dyslexia, etc.). You will then be able to provide additional information.

Access Requirements *Please detail any access requirements, eg wheelchair, vision impairment, dyslexia, etc. so that our staff can make accommodations.

Medical Issue? *Please select 'Yes' if there is any important medical information that we should be aware of (eg epilespsy, asthma, diabetes, ADHD, dyslexia, and all food or medicine allergies etc.). You will then be able to provide additional information.

Medical Information *Please detail any important medical information that our staff should be aware of (eg epilespsy, asthma, diabetes, ADHD, dyslexia, and all food or medicine allergies etc.) and details of any medication prescribed.

How will you travel to the course and who will collect *

Parent/guardian/carer permission *YesBy ticking this box I confirm that I have the permission of the parent/guardian/carer shown on this form, to participate in this course.

Permission to use Photographs and Videos *YesNoWe wish to take photographs and/or videos of students on the Active Leader course, which may feature the student named on this form. Please select 'Yes' to confirm that you and the parent/guardian/carer shown on this form grant us, Cherwell District Council and Active Oxfordshire permission to use photographs and/or videos of you, your name and spoken words in accordance with the terms of use the Active Leader privacy policy which can be found on the Active Leader 'our privacy policy' website link below.

Data Protection *YesBy checking this box you confirm that we may contact you and your parent/guardian/carer and emergency contacts using the contact details you have provided and that we may hold this information in accordance with our Privacy Policy. The information on this form will also be shared with the Accredited Active Leader Trainers, and with Cherwell District Council.

Credit / Debit Card details for £50 charge *

Please enter the 16 digit long card number, the expiry date in MM/YY format, and the CVC code - the last 3 digits on the back of the card. Your credit/debit card will be charged £50.