Registration - Kilcooley Womens Centre

Registration Form

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Step 1 of 4

Your Name (including your title) *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth *

Contact number *

Layout

National Insurance No *

Gender *

Kilcooley Resident *

NIHE Resident *

What is your Nationality? *

What is your country of birth? *

Which one of the following groups do you consider yourself to belong to? *

Do you have a Disability or Medical Condition? *

Disability and Health Conditions: Refers to participants who have a current disability covered by the 1995 Disability Discrimination Act, defined as a disabled person as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities.

About You

I would like to receive communications from Kilcooley Women’s Centre in relation to future activities or courses. *

Do we have your permission to use any photographs we may take of yourself for publication purposes? *

Yes
No (If No it is your responsibility to avoid cameras whilst taking part in activities)

Are you under 18? *

DATA PROTECTION DECLARATION UNDER GDRP: I confirm I give my consent to the processing of my personal data for 1 or more specific proposes. I understand information will be used in accordance with requirements of funding organisations; and the legitimate interests pursued by the controller or 3rd party except if overridden by interests and fundamental rights and freedoms of the data subject which requires protection of personal data, especially of a child. This will not be applied to processing by public authorities and government departments in the performance of their tasks. PARTICIPANT DECLARATION: I declare that the details given on this form are true to the best of my knowledge and maybe kept for as long as required. Any personal information about you or your family that is contained within our filing system (computer or manual) will only be used for the purposes for which it was collected. I agree to abide by the rules of Kilcooley Women’s Centre as outlined in the group rules.

Today's Date *

028 9147 8292

Registration Form

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