Form - victastudents.org.uk

Parent/Guardian

First name *

Last name *

Email *

however for for

Address line 1 *

Address line 2

City *

Post code *

Contact phone number *

Details of your VI child

Please fill out the details for your child who has a visual impairment, although children are not attending this is required for our information and planning.

Child's first name *

Child's last name *

Child's date of birth *

Is your child *

Blind
Partially Sighted

Is your child registered for their vision impairment? *

Yes
No

Name of child's eye condition? *

Share your World Book Day entry

Share a piece of writing about your favourite book, author or character:

Share a link to your video review (or email the video or audio to us at students@victa.org.uk - for large files you can use wetransfer.com)

Upload a photo or piece of writing

Click or drag files to this area to upload. You can upload up to 5 files.

Upload a photo or piece of writing

You can upload your photo as a jpeg or a document containing your piece of writing here. If you have any difficulty uploading your files, please email them to students@victa.org.uk after submitting this form.

Supporting documentation

If your child is registered for their visual impairment, please include a copy of one of the following registration documents: - Certificate of Visual Impairment (CVI) - Blind Registration Card issued by local authority - Letter from the local council confirming the person to be registered If the applicant is not registered, please provide: - a letter from an ophthalmologist confirming visual acuity. Please note, applications cannot be processed without these documents.

Uploading documents

If you would like to upload any supporting documents such as a copy of your registration document, you can do so here (please supply a jpg or pdf). If supplying a CVI, please include Parts 1 & 2. If you are including a copy of a Blind Registration Card, please remember to include both sides. Only files saved as a jpeg or pdf formats will be accepted by the upload. Alternatively, you can email them to parents@victa.org.uk. Please note, We know, that with very young children, you may not have reached registration stage yet, however we will still ask for some form of documentation which helps us understand your child's eye condition. If you need some more information or help, please just send us an email after submitting this form.

Click or drag files to this area to upload. You can upload up to 3 files.

Declaration, privacy and consent

To be signed by the applicants parent/guardian. I confirm that this form has been completed accurately and I undertake to update VICTA should any information contained on the form or personal circumstances change. By signing this form you consent to VICTA and the British Wireless for the Blind Fund using the information supplied for the purpose of administering the offer. All the information will be treated in the strictest of confidence and made available only to those staff working on the offer. Contact information will be retained and used for marketing of other relevant services. I give consent for VICTA and the British Wireless for the Blind Fund to carry out the following in accordance with the UK General Data Protection Regulations as supplemented by the Data Protection Act 2018 and related laws and to store my personal information on both VICTA's and the British Wireless for the Blind Fund's database and/or any other suitable system.

Agreement to declaration *

I agree
I do not agree

Signed (insert name) *

Date *

My relationship to the applicant (if applicable)

Parent
Legal guardian
Other

If 'other' please state

As a recipient of a Voxblock audio book reader VICTA will share applicants details with the British Wireless for the Blind Fund (BWBF) who have provided the offer. BWBF would also like permission to contact you by email and to send a welcome pack by post. Please indicate below how you are happy for them to contact you (select all that apply). *

By post
By email
Neither

How did you hear about this offer? *

Would you like to be added to the VICTA email database to be kept up-to-date with charity news and new activities? *

Yes
No
I'm already signed up

Would you be happy to be contacted for feedback by VICTA and the British Wireless for the Blind Fund on the Voxblock book reader? *

Yes
No

Voxblock World Book Day offer

Parent/Guardian

Details of your VI child

Share your World Book Day entry

Upload a photo or piece of writing

Supporting documentation

Uploading documents

Declaration, privacy and consent