June 2017 Confidence & Resilience Taster Day

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To confirm a place on the Confidence & Resilience Course, please fill in the short form below and a member of our team will be in touch with you shortly.

Parent/Guardian Name *

Email Address *

Contact Number *

Emergency Contact Number (must be different to the number above) *

Home Address *

(Required for invoicing)

Child's Name *

Child's Date of Birth *

YYYY

Child's current school year *

Year 3

Year 4

Year 5

Year 6

Year 7

Child's current school *

Secondary school(s) your child is attending/ applying to *

Whilst we cannot tailor the course to individuals, it is very useful for us to have a sense your child's key development areas. Please could you tick the characteristics below which you believe your child would benefit from developing. *

If you feel that they could develop many of the characteristics, please only tick the top 3.

Welcoming feedback and applying lessons learnt

Coping well in high pressure situations

Coping well with failure

Acknowledging the ability to improve in areas of weakness

Having confident body language including good eye contact & a firm handshake

Confidently putting forward their opinions

Having the tenacity to maintain their opinions, even when challenged

Having the confidence to take the lead as required

Having the confidence to say 'no' to things they don't agree with or feel uncomfortable doing

Required

Your child's interests *

(This is to ensure the course caters for your child and that their 'team leader' is aware of their interests)

Allergies / intolerances that your child suffers from

(Please provide all details. We will cater wherever possible to your child's dietary requirements)

Does your child have any additional needs? If so, please provide some detail including any strategies used to support them

How did you hear about us? *

If you found us online, please specify which channel you heard about us through. It's really useful for us to know!

If you answered 'Other' above, please specify where

If referred by someone please write their name below

Occasionally, we may take photographs of children during Role Models events. To comply with the Data Protection Act 1988, we need your permission before we can photograph your child. In respect to this, the following shall apply: If we use photographs of individual children, we will not use the name of your child in the accompanying text or photo caption. We will only use images of children who are suitably dressed. Please confirm you are happy for us to use these images in our marketing materials or in other printed publications that we produce, as well as on our website? *

Your answer to this question supersedes the marketing section within the T&Cs.

Yes

Please confirm you are happy for us to use any testimonials you send us via email in our marketing materials or in other printed publications that we produce, as well as on our website? *

Yes

I am interested in using childcare vouchers? *

Yes

I confirm that my child will be attending the Confidence & Resilience Course at Chelsea Academy School on June 17th

I accept the Terms and Conditions of the Role Models Confidence & Resilience Course *

To view Terms and Conditions please visit: http://goo.gl/IVwgeX

I accept the Terms and Conditions

Required

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