Whizz Kidz General Application Form

Whizz Kidz General Application Form

We are a disabled children’s charity providing mobility equipment such as wheelchairs and delivering services all across the UK for young wheelchair users.
What we do:

Provide mobility equipment: such as wheelchairs, trikes, buggies and sports wheelchairs for disabled children up to the age of 18.

Whizz Kidz Activity Programmes: For ages 8-25: Our programmes are activities where young wheelchair users can take part in activities such as sports, drama, film and gaming design, days out and loads more! Both in person and online.

Wheelchair Skills Training: For ages 2-25: these sessions will teach young disabled people skills to help them feel safe, develop independence and confidence in their wheelchair.

Employability Sessions: For ages 14-25: these will help young people learn valuable and essential skills to build their CV and prepare them for the world of work.

Your personal information

We need to collect certain personal information from you in order to process your application and to support your ongoing care needs whilst attending our services.
This will include medical information.

We recognise the sensitivity and importance of personal information and treat it securely. By submitting your application you agree that we may store, disclose or transfer the sensitive personal information it contains to those employees of Whizz Kidz who will process your application.

Whizz Kidz may also be required or permitted by law to share your personal information.

Please note that you can withdraw your application at any point. You can also request to see any records which we hold about you. Our Privacy Statement is available here.

Please ensure you answer every question on this form.
First Steps
Name of person completing this form*
Relationship to Young Person:*
Phone Number:*
To apply for any of our services or equipment you must agree to the statement below:
I/the person I am applying for has a physical disability and need a wheelchair for everyday activities and participation*

Agree
Please indicate which Services you are applying for (you can tick more than one):*

EquipmentProgrammesWheelchair skills trainingEmployability
If you are applying for equipment, you will be required to complete a second form with some additional information. This will be available upon completion of this form.

Personal information

About you - please enter the details of the young person who is applying for equipment or services
Name*

First NameLast Name
Preferred name*
Address*

Street Address

Street Address Line 2

CountyState / Province

Postcode
Email address*
example@example.com
Phone Number*
Date of Birth*

DayMonthYear
Date
Gender*

MaleFemalePrefer not to sayOther, please state
Preferred Pronouns*

She/HerHe/HimThey/ThemOther, please state
NHS/CHI No

Getting in contact with you

Whizz Kidz may need to contact you with important information relating to your application, by providing this information you are consenting to us contacting you directly. Please refer to our Privacy Policy for more information: www.whizz-kidz.org.uk/privacy
The fastest way for us to contact you is if you can provide us with an email address and a mobile phone number.

Parent / (carer) information – please confirm two primary contacts

Contact One
Relationship to young person*
Title (e.g. Mr / Mrs / Ms)*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CountyState / Province

Postcode
Email address*
example@example.com
Phone number*
Additional phone number (work etc)
Contact two
Relationship to young person*
Title (e.g. Mr / Mrs / Ms)*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CountyState / Province

Postcode
Email address*
example@example.com
Phone number*
Additional phone number (work etc)
Emergency Contact Information

In the event of an emergency at a service we will attempt to contact your two primary contacts. However, we also need a third person’s contact details in case we are unable to contact them. Please provide details of a third emergency contact below.
Name*

First NameLast Name
Relationship*
Phone number*
Additional number
School or college you attend
Are you in formal education?*

YesNo
If yes, please complete following sections below
Name & Address of preschool / school / college / university
Name, role/job title, email address and phone number of a member of staff who knows you well at school/college/university

Photography, Video and Story Consent Form
We often take photographs and videos at our services, events and clinics. We also like to capture the stories of our beneficiaries, fundraisers, and volunteers. It’s a great way to show the work that Whizz Kidz does, to help us increase awareness and raise the vital funds we need to continue our work.

By ticking the below box, you give your consent for Whizz Kidz to take photographs, videos and audio recordings of you, to share your story, and to use them in Whizz Kidz’s communications, marketing, press activity, awareness raising and fundraising campaigns.

Whizz Kidz for these purposes means the charity (number 802872) a company limited by guarantee under company number 2444520.

Declaration:
I authorise Whizz Kidz to take/and or use pictures, photographs, video recordings, audio recordings, digital images, and the like of me (the "Images"), and to use my story, for any lawful purpose in connection with Whizz Kidz's charitable objectives.

Whizz Kidz can include this in any of the following:
- Printed materials (posters, flyers, leaflets, booklets, reports)
- Online and print media (websites, social media, newspapers, magazines)
- Broadcast media (television and radio)
- Advertisements
- Presentations
- Fundraising applications/mailing campaigns
- Materials produced for or by our external partners
- Any other use where the aim is to further Whizz Kidz's charitable objectives.
If the Images are accompanied by a description, Whizz Kidz can include my name in the description.
- Furthermore,I assign to Whizz Kidz any interest in copyright or other intellectual property rights that I may have in the Images.
- I will not object to or restrict Whizz Kidz's use of the Imagess and stories for the purposes specified above.
- I will not bring any claims for damages against Whizz Kidz in connection with their permitted use of the Images and stories.
- I understand and agree that Whizz Kidz will not pay me, now or in the future, for any use of the Images and stories.
Whizz Kidz promises to look after your personal information (including photos and videos of you) in accordance with the GDPR. You can read more about how Whizz Kidz will look after your personal information in our privacy policy: www.whizz-kidz.org.uk/privacy
I have read and understand this Photo, Video and Story Release Form

Please tick the box to confirm consent
Regardless of this consent, Whizz Kidz is not responsible for photos taken by other parties.

If you change your mind or have any questions about how Whizz Kidz look after your personal information, including photos and videos of you, please read our Privacy Policy or contact us at data.protection@whizz-kidz.org.uk. If you would like revoke your consent for Whizz Kidz to store or use images or videos of you please contact Whizz Kidz at data.protection@whizz-kidz.org.uk.

PLEASE NOTE: If you have any questions or queries relating to the contents of this Photo, Video and Story Release Form please contact the Whizz Kidz Communications Team on communications@whizz-kidz.org.uk.
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Whizz Kidz General Application Form

What we do:

Your personal information

First Steps

Personal information

Getting in contact with you

Parent / (carer) information – please confirm two primary contacts

Emergency Contact Information

School or college you attend

General medical information

Further specific conditions

Your Mobility Aids and Abilities

Mobility

Communication

Final questions

Language

Sexual Orientation

Communications & Privacy Preferences

Sharing medical information

Do you want to receive updates from Whizz Kidz?

Photography, Video and Story Consent Form