RCPH Debate and Mentorship Application

Name of Learner*

First NameLast Name
Age*
Date of Birth*

MonthDayYear
Date
ID or Passport Number*
Learner's Contact Number*
Please enter a valid phone number.
Name of Parent/Legal Guardian*

First NameLast Name
Parent/Legal Guardian's Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Home Address*
Name of School*
Grade*
Class teacher*
School address*
Please describe any previous debating experience or let us know if this will be your first time*
Are you currently involved in any youth/community projects? If yes, please provide name of organisation and/or project*
Which device/s do you have access to? Select all that apply*

SmartphoneTabletLaptopDesktopNone of the above
Do you have access to Wifi or Data for the online sessions? Select all that apply*

WifiMobile DataNone of the above
If you do not have access to Wifi or data, we can provide you with assistance. Please let us know in the comments section below.
Parental Consent
Parental consent is required to participate. Please ensure this form is signed and submitted by a parent or legal guardian.
Full Name of Parent/Legal Guardian*

First NameLast Name
Signature*
Please verify that you are human*
POPIA ACT

The Protection of Private information act (POPIA) came into play on the 1st July
2021. At the Rotary Club of Pretoria Hatfield, we don’t share or sell your
personal information as we honour your right to privacy and data protection.
We have taken every precaution to ensure the safety and confidentiality of
your personal information.

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Parental Consent