Please complete this form if you would like to take part in NCS with Scunthorpe United CSET. Once this form has been completed, please send your £50 payment to Sam Tonge, Glanford Park, Jack Brownsword Way, Scunthorpe, North Lincolnshire, DN15 8TD (Cheques made payable to Scunthorpe United Trust) or visit the Old Show Ground bar at Glanford Park to deliver it to the Trust in person. For further information please email

participant’s details

Spring Summer Autumn

Male Female Prefer not to say

Parent or Guardian Details


How did the Participant hear about NCS?
(Please tick all that apply)

What was the last School / College the Participant attended or is still attending?

What is the Participant currently doing?
(Please tick all that apply)

What best describes the Participant's ethnic background?
(Please tick one)

What is the Participant's faith / religion?
(Please tick one)

Yes No Prefer not to say

If yes, which of the following describes the Participant's disability?
(Please tick all that apply)

Yes, they have tried helping out or volunteered Yes, they have regularly helped out or volunteered No, they haven't helped or volunteered

Does the Participant face any specific issues or barriers to participating in activities?
(Please tick all that apply)

Yes No

Disclaimer and Medical Statement

(Please tick the relevant box, providing further information if required)

Yes No

Yes No

Yes No

Yes No

Yes No


  • Staff are not permitted to take responsibility for or to administer medicines. You are therefore responsible for ensuring any medicine is available and taken correctly
  • You understand that whilst involved in the programme activities the Participant will be under the care of the community trust staff and other suitably approved adults. Whilst we will take all reasonable care of Participants you acknowledge that in the absence of our negligence, participation in the programme is at your sole risk and that we shall not be liable for damage or injury arising from activities

In the unlikely event of an accident occurring, you provide your permission for a designated representative of the community trust to authorise emergency medical treatment, including the use of anaesthetic if deemed necessary.



  • During the course of NCS, activities may be recorded through photographs and video film both for the Participants to collate and celebrate their experiences but also for evaluation and promotional purposes by the community trust, The Football League Trust, the Cabinet Office and partner agencies.

You agree that the images may be used in media or publicity materials and celebration publications produced by those agencies.

You understand that these images may be safely stored or archived digitally or manually and may be publicised in a variety of media forms including managed social network sites.

Emergency contact details

In case of an emergency, who should we contact?

Further Information

To receive further information about Scunthorpe Trust and related activities please provide a mobile number and / or email address:


The standard price of NCS is £50 as a contribution towards the entire costs. Financial support to reduce the cost may be available if required (for example if your son/daughter is entitled to free school / college meals). Please contact us at for more information.

Payment Method

To secure your son/daughter's place you can pay via debit / credit card, cheque or cash. Our debit/credit card option will appear once you have completed and submitted this form. If you are paying via cheque, you can make a cheque payable to Sports Trust and this can be delivered to Scott Maxfield, Scunthorpe Trust, Glanford Park, Jack Brownsword Way, Scunthorpe, North Lincolnshire, DN15 8TD or Cash can also be haded in at the Main Reception, Glanford Park, Jack Brownsword Way, Scunthorpe, North Lincolnshire, DN15 8TD.

Acceptance Statement

Consent For Water Related Activities

Travel and Collection Statement


  • During the programme the Participant will be responsible for getting to and from agreed venues, and will be allowed to leave without collection.
  • For the residential venues or where transport facilities are provided as part of the project, the Participant will be responsible for getting to and from the designated meeting location. Participants will not be allowed to leave other than from that location, but will be permitted to leave from that location without collection.
  • During the activities, for example as part of the Social Action Project, the Participant may be required to undertake travel unsupervised, either on foot or by public transport.

You give us permission to allow the Participant to leave designated locations (other than the residential or supervised trips) without collection, and to undertake some travel unsupervised

Once Completed we recommend that you take a copy of this form for your own Records