Kicks - Registration Form
Privacy and Consent - PLEASE NOTE ONCE YOU'VE SUBMITTED THAT YOU HAVE CONFIRMED YOUR PLACE
I consent to Newcastle United Foundations Privacy Policy.
Please Select
No
Yes
I consent to Newcastle United Foundations Code of Conduct
Please Select
Yes
No
Which Programme are you attending?
Which Kicks session is the participant attending?
Please Select
Alnwick - 5-7pm (Monday)
Ashington Hirst Welfare (13-18 Years) - 6:30 - 8pm (Friday)
Ashington Hirst Welfare (8-12 Years) - 5-6:30pm (Friday)
Berwick Kicks - 4-7pm (Friday)
Blakelaw - 6-8pm (Monday)
Byker Primary School (Multi-sports) - 4:30 - 5:30pm (Thursday)
Byker Primary School - 3:30 - 5:30pm (Tuesday)
Howdon Community Hub Kicks - 5-7pm (Thursday)
NUCASTLE (Girls Kicks 11-13 years) - 6:30 - 7:30pm (Monday)
NUCASTLE (Girls Kicks 8-10 years) - 5:30-6:30pm (Monday)
NUCASTLE Kicks Gaming - 5-7pm (Thursday)
NUCASTLE Kicks Gaming - 5-7pm (Tuesday)
Neurodiverse (NUCASTLE) - 6-7pm (Thursday)
Neurodiverse (The Parks) - 6-7pm (Wednesday)
The Parks - 6 - 8 (Friday)
Walker Activity Dome Kicks - 6-8pm (Thursday)
Westgate Soccerworld (14-18 Years) - 6:30-8pm (Friday)
Westgate Soccerworld (8-13 Years) - 5-6:15pm (Friday)
Are you a Bernicia resident?
Please Select
No
Yes
How did you hear about PL Kicks?
Please Select
Care Home/Supported Accommodation
Council Ward
Family or Friends
Northumbria Police
School
Youth Organisation or Community Group
Contact Information
Forename
Surname
Date Of Birth
Day
1st
2nd
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4th
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Month
January
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Year
2035
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1918
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1914
1913
1912
1911
1910
Parent/Guardian Mobile
Parent/Guardian Email
Photo/Filming Consent
Please Select
No
Prefer not to say
Yes
Do you give consent for young person to walk home unsupervised?
Please Select
No
Yes
Demographic
Gender
Please Select
Female
Male
Non-binary
Other
Prefer not to say
Transgender Female
Transgender Male
Other
Ethnicity
Please Select
Asian/Asian British - (Unspecified)
Asian/Asian British - Bangladeshi
Asian/Asian British - Chinese
Asian/Asian British - Indian
Asian/Asian British - Other
Asian/Asian British - Pakistani
Black/African/Caribbean/Black British - (Unspecified)
Black/African/Caribbean/Black British - African
Black/African/Caribbean/Black British - Caribbean
Black/African/Caribbean/Black British - Other
Mixed/multiple ethnic groups - (Unspecified)
Mixed/multiple ethnic groups - Other
Mixed/multiple ethnic groups - White and Asian
Mixed/multiple ethnic groups - White and Black African
Mixed/multiple ethnic groups - White and Black Caribbean
Other ethnic group - Arab
Other ethnic group - Other
Prefer not to say
White - (Unspecified)
White - Eastern European
White - Gypsy, Roma or Irish Traveller
White - Irish
White - Other
White - Welsh/English/Scottish/Northern Irish/British
Religion
Please Select
Buddhist
Christian (all denominations)
Hindu
Jewish
Muslim
No religion
Other
Prefer not to say
Sikh
Disability
Please Select
No
Prefer not to say
Yes
Disability - please state
Hearing impairment (deaf or hard of hearing)
Learning difficulty (e.g. movement co-ordination difficulty (Dyspraxia, Dyslexia, etc.)
Learning impairment/disability (eg. Down's syndrome, etc)
Long term illness (eg. cancer, HIV+ etc)
Mental health condition (eg. depression, schizophrenia etc)
Other
Physical impairment - ambulant (I do not use a wheelchair)
Physical impairment - wheelchair user
Prefer not to answer
Social/communication impairment (eg. autistic spectrum disorder, Asperger's syndrome etc)
Visual impairment (blind or partially-sighted)
Sexual Orientation
Please Select
Bisexual
Gay or Lesbian
Other
Prefer not to say
Straight or Heterosexual
Does the participant receive free school meals?
Please Select
No
Yes
Address
Address line 1
Address line 2
Post Code
Medical Information
In the event that I get injured while attending a course or activity, I give my consent to receive medical attention.
Please Select
No
Not Given
Yes
Do you have any medical conditions or require medication to safely participate in a session?
Please Select
No, I do not have any medical conditions or medication requirements
Other
Prefer not to say
Yes, I have a medical condition and require medication
Yes, I have a medical condition but do not require medication
What medical condition do you have?
Please Select
ADHA
ADHD
Allergies
Anxiety
Asthma
Brain Injury
Cancer
Cancer1
Chrons
DVT
Dementia
Depression
Diabetes
Epilepsy
Functional Neurological Disorder
Hiatus Hernia
High blood pressure
Marfan Syndrome
None
Osteo Arthritis
Other
Prefer not to say
Schizophrenia
Do you take any medications that you think we should know about (for a disability or medical condition) that might impact your participation in this programme?
Do you have any access requirements that we need to be aware of?
Emergency Contact Details
Emergency Contact Forename
Emergency Contact Surname
Emergency Contact Mobile
Relationship to participant:
Please Select
Foster Carer
Legally appointed guardian
Parent
Declaration
I confirm that I have provided consent to take part in this programme
Please Select
No
Yes
The information provided in this form is to the best of my knowledge and is accurate
Please Select
No
Yes
Newcastle United Foundation would also like to obtain photography and videography for evaluation and publicity purposes - Please tick below the additional information you are happy to consent to.
I do not consent
I provide consent for images being used for reporting only.
I provide consent for my images to be shared with Newcastle United Football Club.
I provide consent for my images to be used for evaluation and publicity.
Do you give consent for Newcastle United Foundation to send you news and updates to your registered email address?
Please Select
No
Yes
Submit
