Panna Kicks NI @ Strathroy Community Centre

Section 1

Details of person completing application form
Name of person completing application form*

First NameLast Name
How do you know the attendee?*
For example, parent, guardian, grandparent, social worker etc.
Contact number of person completing application form*
Mobile or Landline
Email (for all correspondence)*
** Please ensure that you check your spam / junk folder regularly encase correspondence gets diverted **
Section 2

Attendee Details / Permissions
Attendee Post - Code*
Attendee Name*

Attendee ForenameAttendee Surname
Attendee Gender*

FemaleMalePrefer not to say
Attendee Age*
Attendee Date of Birth*

DayMonthYear
Date-Month-Year Format
Attendee Medical and/or Disability Considerations*
None = N/A
Please provide details above regarding any medical and/or disability considerations coaches may need to be aware of in relation to the attendee; this also includes details regarding any allergies. If there are no medical and/or disability considerations, please write N/A.
Attendee Photography and/or Filming Permission*

Yes - permission is authorisedNo - permission is not authorised
Please indicate above (by selecting either 'Yes' or 'No') if permission is authorised for the attendee to be photographed and/or filmed whilst participating in activities associated with the programme.

Images may be used in local media, programme review documents, online and shared with partner organisations (for example, Sport Northern Ireland, Department for Communities (DfC) involved within the programme.
Section 3

Emergency Contact Information
Please provide details below for x2 emergency contacts.

Emergency contact 1 (primary) will be contacted in the first instance. Emergency contact 2 (secondary) will be contacted if the primary contact does not respond.

Emergency Contact Information *

	Name	Contact Number
Emergency Contact 1 (Primary)
Emergency Contact 2 (Secondary)

Section 4

Data Protection
In accordance with the Data Protection Act 2018, Fermanagh and Omagh Distrct Council has a duty to protect the information we hold on you. The personal information you provide on this form will only be used for the purpose of the programme you are attending. Information will be shared with relevant individuals, partner organisations and coaches (who may have been externally appointed to deliver the programme) to facilitate delivery.

Information will not be shared with any other organisations or individuals unless law or regulation compels such a disclosure.

For further details on how we hold your information, please visit the Privacy Section on the Council website, https://www.fermanaghomagh.com/your-council/privacy-statement

* Please select 'Yes' below (Data Protection Acknowledgement) to confirm that you have read and understood that information provided on this application form will be shared with relevant individuals, partner organisations and external coaches to enable the delivery of the programme.
Data Protection Acknowledgement*

Yes
Section 5

Programme Selection
Strathroy Community Centre // Commencing Saturday 2 March 2024 @ 10.45am - 12.15pm (x3 - weeks) // Age = 6 - 13 yrs
Should be Empty:

Section 1

Section 2

Section 3

Section 4

Section 5