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Irlen Syndrome
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Irlen Consent & Confirmation Form
Irlen Consent & Confirmation
"
*
" indicates required fields
Step
1
of
2
- Consent form
50%
Child / Young Person's details
Name
*
Dr
Miss
Mr
Mrs
Ms
Mx
Title
First
Last
Date of Birth:
*
DD slash MM slash YYYY
Age
*
Gender
*
Male
Female
Non-binary
Other
Preferred Pronouns
*
He/his
She/her
They/them
Parent/Carer details
Title
*
Preferred Pronouns
*
He/his
She/her
They/them
Name
*
First
Last
Relationship to the young person
*
Address
*
Street Address
Address Line 2
City
County
Postcode
Daytime phone: Mobile phone
*
Email Address
Alternative contact details
In case of an emergency and we're unable to get hold of you.
Title
Preferred Pronouns
He/his
She/her
They/them
Name
First
Last
Relationship to young person
Their daytime phone
Their mobile phone
Consent to take part
*
I am happy for my child to take part in this assessment. I understand that, while bibic will take all reasonable care of my child, unless they are negligent, they cannot be held responsible for any loss, damage or injury suffered by my child.
Yes
No
Consent to authorise medical treatment in an emergency
*
I give consent for bibic to administer basic first aid, and/or authorise medical treatment (as advised by medical staff) should it be deemed in the interest of my child’s health and safety to do so.
Yes
No
Consent to take and use photographs/videos of young person
*
Featuring family stories, photos, videos and quotes in our marketing and communications can help bibic raise more money or help other families understand how bibic can help their child.
I am happy for photographs and/or video of my child to be taken whilst taking part in the sessions and used to publicise the work of bibic and to our funders, and other fundraising purposes. To protect privacy we will not use names unless the child is part of our Sponsor a bibic child programme.
Yes - Both images and video
Yes - Images only
Yes - Videos only
No
Consent to store and process data
*
I consent to our data being gathered, stored and processed (in line with our privacy policy) so that bibic can provide support to my child. I understand that these details will be kept for up to 7 years. All data will be securely stored and not shared with any third parties.
Yes
No
Consent to be contacted by our Fundraising and Marketing department
*
bibic need to raise £1,485 towards the cost of every full assessment, therapeutic plan and support for families. We would like to keep in touch with you about fundraising and marketing. I consent to bibic contacting me about fundraising events, activities, and marketing.
Yes
No
I would like to be contacted by:
We will keep your information secure. You can change how we contact you at any time by:
• Email info@bibic.org.uk
• Calling 01458 253344
• Writing to bibic, Old Kelways, Somerton Road, Langport, TA10 9SJ
Post
Email
Phone
Signature
*
Reset signature
Signature locked. Reset to sign again
Signature date
Confirmation Form
Please read all the information and ensure you understand it fully, failure to do so may result in a fee being applied or the assessment being cancelled.
Cancellation and admin fees
There is a 48 hour cancellation period. If cancelled before this, we are able to rearrange your assessment. If you cancel within 24 hours we will keep 50% of the fee paid.
Cancellation fee consent
*
I agree to pay any cancellation fees applicable.
*
Attending
*
I confirm that we will be attending our assessment. (During assessment student placements may be present.)
Payment
We require full payment before your assessment date.
How are you paying?
*
Option 1 - I have paid in full
Option 2 - I will pay in full
Option 3 - I will pay in two halves
Please select the relevant option and fill in the below:
*
I have paid the below amount by card over the phone
I have paid the below amount via internet banking
I have sent a by cheque for the below amount
Date payment made
DD slash MM slash YYYY
Please enter the date your payment was made.
Please select the relevant option and fill in the below:
*
I will pay the below amount by card over the phone
I will pay the below amount via internet banking.
I will send a cheque for the below amount
Date payment will be made
DD slash MM slash YYYY
Please enter the date you will make the payment.
Please select the relevant option and fill in the below:
*
I have paid the below amount by card over the phone and will pay the remaining balance
I have paid the below amount via internet banking and will pay the remaining balance
I have sent a cheque for the below amount and will pay the remaining balance
Date of first payment.
MM slash DD slash YYYY
Date of second payment.
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.
