DICE PARTICIPATION MEMBERSHIP FORM 2024
Step
1
of
2
50%
Person making this application is? Please enter your name and email adress below.
How did you hear about Dice Enterprise?
*
Facebook
Linkedin
Sign posted by a professional
At an Dice event
Word of mouth
Social Worker
Other
Participants Full Name
*
First
Middle
Last
Participants Date of birth
*
Participants DICE Membership Number:
This will be on the back of the card. Skip if not applicable or recieved as of yet.
Email
*
Enter Email
Confirm Email
Are you happy for Dice to contact you by email regarding our events and any cancellations?
Yes please.
No thank you.
Participants Mobile Number
Skip if N/A
Participants Address
*
Street Address
Address Line 2
City
County / State / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Emergency Main Contact Details
*
Emergency Second Contact Details
Does the participant have a social worker?
*
Yes (if yes please provide their contact number and email address details below)
No
Unsure
Social Workers Details.
Skip if not applicable.
I/they live
*
On their own.
With Family or Friends
In supported living
In residential care
Please provide details of the participants disability and/or medical conditions.
*
Please provide details of any allergies the participants has. E.g. Hayfever, Nuts.
*
Please state the above.
Please provide details of the participants dietary requirements or food preferences?
*
Please state the above.
Will the participant need our support with medication, if attended one of our residentials?
*
Yes (if yes, please discuss this with a Dice staff member)
No
Does the participant have any challenging behaviours?
*
Please state the above. Enter N/A if not applicable.
Does the particpant need support with toileting?
*
Yes (if yes, please discuss this with a Dice staff member)
No
Please provide any other information about the participant that will help us to better support and enable them to enjoy their time at Dice.
*
Can the participant stand and move between 1 and 20 metres without any help?
*
Yes
No
Can the participant walk more than 300 metres?
*
Yes
No
Will the participant be using a wheelchair or scooter while at our events?
*
Yes
No
Are you willing to be filmed & photographed for promotional purposes? This may include web publishing and social media.
*
Yes i consent
No thank you
Do you consent to a trained first aider treating minor injuries?
*
Yes i consent
No thank you
Will the participant be attending our events with their own support staff?
Yes
No (Participant does not require any support with toileting, medication or have any serious behaviour challengers))
Not sure
Please provide details of the person who we would need to contact regarding any payment enquiries?
Email, address, contact name, and phone number.
Are you happy for us to contact you using the details provided?
Yes
No
Not applicable
What is the best way for us to share information with you?
*
By Text.
By Email.
Would you like to pay for your membership today?
Yes
No
Already paid at an event.
Paid through the Dice website.
Dice Participation Membership.
Quantity
Price:
£ 35.00
Quantity
Credit Card
Please check if you have activated a Stripe feed for your form.
Total
Evidence of Age & Disability.
*
I agree i will show this evidence.
This may be required. One is required for each Age (Birth Certificate, Passport, Driver’s License, Pension Book) Disability (Letter or bank statement detailing disability benefits, disability living allowance, incapacity benefits or severe disabled allowance) If you do not have any of the above documentation, please speak to a member of the team to discuss alternative options.
By ticking the box, you have read and agree to our GDPR policy.
*
i agree
GDPR; As part of the registration process for our Membership, we collect personal information. We use that information for a couple of reasons: to tell you about our events and information, you’ve asked us to tell you about; to contact you if we need to obtain or provide additional information; to check our records are right and to check every now and then that you’re happy and satisfied. We don’t rent or trade email lists with other organisations and businesses. All our data is logged onto our private system which is encrypted. All personal paper data is shredded and disposed of in the correct method. We also use an online mailing system for sending our information by Wix.com please see their privacy policy. https://www.wix.com/about/privacy
Name
This field is for validation purposes and should be left unchanged.