DICE Participation Membership Form
We require every member to fill out this form.
Step
1
of
2
50%
Members Full Name
*
First
Middle
Last
Date of birth
*
Your Order Number:
You can find this in your confirmation email.
Email
*
Enter Email
Confirm Email
Members Phone Number
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
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Greenland
Grenada
Guadeloupe
Guam
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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
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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 Contact Details – Number One
*
Emergency Contact Details – Number Two
Please provide details of your disability and medical conditions. Please include any allergies. E.g. Nuts
*
Do you have any hints and tips on how we can help you when you are at our activities, so you enjoy it the most and get more from your visit?
*
How did you purchase your membership?
*
Website
At one of our events
Other
Are you willing to be photographed for promotional purposes? This may include web publishing and social media.
*
Yes i consent
No thank you
Are you willing to be filmed for promotional purposes?
*
Yes i consent
No thank you
Do you consent to a trained first aider treating you or the members if required?
*
Yes i consent
No thank you
Please advise below any other information you feel may be helpful to us in assisting you to enjoy your experience and also assist us with dealing with any situations relating to behaviour or habits.
*
How do you want us to share our good news and success stories with you?
*
By Text.
By Email.
By Post.
Prefer not to be sent any information.
Dice Acceptable Behaviour Contract
Tick once read. The DICE social pub is a great place where adults aged 18+ with a disAbility attend and enjoy a night out in a safe and fun environment with their friends. It is not a youth club and it is not a place where bullying or bad behaviour will be accepted or tolerated. 1. No Swearing or Bad Language 2. No Physical Violence (Hitting, pushing, Spitting, dragging etc) 3. No Bullying (Verbal, Psychological or Physical) 4. No Throwing of any objects 5. Do not bring your own food & drinks into a venue that already sells them. Anyone found consuming drinks not purchased from the Pub will be suspended for a minimum of 1 month. 6. No going into rooms or areas of the venue that are not being used by DICE. 7. Smoking only permitted in the designated spaces 8. Personal space. Be mindful that people have different tolerance levels. 9. Do not damage any DICE or venue equipment or furniture. Treat with respect. All non-accidental damages will be paid for. 10. Do not say something to someone that they may find offensive. 11. Behave in a responsible manner at all times 12. Behave on social media while at DICE (No Cyber bullying) 13. Always follow the instructions of DICE Staff Breaking this contract will result in disciplinary action. This could be a verbal or written warning or suspension dependant on the seriousness of the incident.
Evidence of Age & Disability
I agree i will show this evidence.
One 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.
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
Email
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