Kilmarnock - Off The Bench nomination form
The following information gathering will allow us to ensure we have the relevant information per person in relation to the needs of the programme. By completing this form you are agreeing for someone to contact you regarding your involvement in Off the Bench. This information will only be shared with relevant staff from the SPFLT and The Killie Community who are delivering Off the Bench and Scottish Government (who fund the programme). If you have any queries about the information that is being requested, please contact Grant Wallace grant@killiecommunity.co.uk
Name
First Name
Last Name
Date of Birth
Age
16-18
19-24
Over24
Prefer to be known as
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Why would you like to attend Off the Bench?
Are there any reasons why you might not be able to attend?
Is there anything that would help you attend?
Self nomination
Yes
No
If no - nominee name and organisation
If yes - referee name
Referee Organisation
If you are completing the form on behalf of the young person please complete the following
Name
Email
Phone number
Organisation
Organisation website
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: