Registration- Samuel Rhodes School

Welcome to Envision! To confirm your registration, please complete this short form.

Contact Details:

First name*   Last name*
Address*   Date of Birth*
Postcode*      
         
Home Phone   Mobile Phone
Email

Emergency Contact:

First name*   Last name*
Relation to you (eg mother)*   Emergency contact number
Allergies/Special dietary requirements

Diversity & Monitoring:

Ethnicity*   Specify if other
Faith*   Specify if other
Do you consider yourself to have a disability?*
If yes, what?
Have you taken part in the National Citizen Service (NCS), e.g. The Challenge?
Has anyone in your immediate family been to university?
Have you ever received free school meals?
Have you previously volunteered?

I rate myself:

On a scale of 1-10 (1 is strongly disagree, 10 is strongly agree), how much do you agree with these statements?

I believe that my actions can make a difference
I can demonstrate the competencies that employers are looking for
I know what role I am best suited to in a team
I spend time trying to find out about social and environmental issues
I feel part of my local community
I feel responsible for making a difference in my community
I am proactive in making a difference in my community

Privacy statement & Declaration: Your address and contact details above will be held by Envision so that we can contact you regarding Envision meetings in your school/college, activities taking place over the year and post you your Envision award in the summer. All other information collected above will be stored securely and anonymously. It will be used for monitoring and statistical analysis purposes. Please sign below to indicate your consent to Envision using the information you have provided for these purposes. We will not pass on your personal information to any other organisation without your consent.

Media Release: I understand that as part of my participation with Envision photos, videos, sound bites and quotations may be taken for use in publications, reports, webcasts, podcasts and press releases and on occasion distributed to news outlets, radio stations and TV companies for the purpose of publicising and promoting Envision’s work. I give my permission to use such materials for the promotion and reporting of Envision’s programmes, projects and events .