Aim Higher Membership Form
Sign up to get access to all our information & events.
Parent/Carers Name
First Name
Last Name
Young Persons Name
First Name
Last Name
Young persons difficulties
Young Persons Address
Street Address
Street Address Line 2
City
Region
Post Code
Your Contact Email
example@example.com
School
Special
None
College
Mainstream
Your Contact Phone Number
-
Area Code
Phone Number
Does the young person have an Education, Health & Care plan?
Yes
No
Waiting
Are there any particular barriers you are facing or worried about?
What support/activities would you like offered to parents/carers?
What support activities would you like to see offered for your young person?
If "Yes", What age please?
Do we have your permission under GDPR to keep your information?
Yes
No
Medical Information
Are there any medical conditions (ie. allergies, epilepsy, asthma, diabetes) which we should be aware of?
Yes/No
Yes
No
If yes please detail below
Submit
Print Form
Child Photo/Video consent
We would be grateful if you would fill in this part of the form to give us permission to take photos of your child and use these on our printed and online publicity.
I give Aim Higher permission to take photographs and/or video of my child. (Parent/Carers Name)
I grant Aim Higher full rights to use the images resulting from the photography/video filming, and any reproductions or adaptations of the images for fund raising, publicity or other purposes to help achieve the groups aims. This might include (but is not limited to), the right to use them in their printed and online publicity, social media, press releases, and fund raising applications. (Parent/Carers Name)
Name Of Child
Name Of Parent/Guardian
Date
-
Month
-
Day
Year
Date
We will hold your details as long as is necessary so as to be able to deliver our services, and continue your membership. By clicking this box I hereby give my permission to the above terms and conditions
I Agree to the above terms and conditions
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