Membership Application

166th (Mickleover) Derby Scout Group

Please use this form to Apply for Membership of any of the 4 Sections in the Group. These details will only be used within the Scout Group and will NOT be passed to any other individual or organisation.
Section *

Squirrels Beavers Cubs Scouts
Young Person's Details
First Name *
Last Name *
Date of Birth *

Day Month Year
Gender *
Ethnicity? *

A1 - White - English, Welsh, Scottish, Northern Irish or British A2 - White - Irish A3 - White - Gypsy or Irish Traveller A4 - White - Roma A5 - Any other White background B1 - Mixed or Multiple ethnic groups - White and Black Caribbean B2 - Mixed or Multiple ethnic groups - White and Black African B3 - Mixed or Multiple ethnic groups - White and Asian B4 - Any other Mixed or Multiple ethnic background C1 - Asian or Asian British - Indian C2 - Asian or Asian British - Pakistani C3 - Asian or Asian British - Bangladeshi C4 - Asian or Asian British - Chinese C5 - Any other Asian background D1 - Black, Black British, Caribbean or African - Caribbean D2 - Black, Black British, Caribbean or African - African background D3 - Any other Black, Black British or Caribbean background E1 - Other ethnic group - Arab E2 - Any other ethnic group F - Prefer to self-describe G - Prefer not to say
Any Medical Conditions or Special Needs that we need to be aware of? *
Dietary Requirements *
Address Line 1 *
Address Line 2 *
Post Code *
Parent or Carer's Details
Title *
First Name *
Last Name *
Phone 1 *
Phone 2
Phone 3
Please Note, the 'Phone 1' number must be the number that we can contact you on whilst your child is in our care.
Parent or Carer's email address *
Application Date *

Day Month Year
Gift Aid Declaration
I want to Gift Aid any donations I make in the future or have made in the past 4 years to: *

Yes No
The name of the Charity is - The Scout Association. The Charity Registration Number is - 306101
I declare that I am a UK taxpayer and understand that if I pay less Income Tax and/or Capital Gains Tax than the amount of Gift Aid claimed on all my donations in that tax year it is my responsibility to pay any difference.
Please notify the Scout Group if you: -

● want to cancel this declaration

● change your name or home address

● no longer pay sufficient tax on your income and/or capital gains

If you pay Income Tax at the higher or additional rate and want to receive the additional tax relief due to you, you must include all your Gift Aid donations on your Self-Assessment tax return or ask HM Revenue and Customs to adjust your tax code.
Photographs and Videos

Images, still or video, of the young person named on this form will not be used in any way unless you give us your consent below: -
Please select one : - *

I am happy for photos and videos of the above named young person whilst undertaking Scouting activities to be published on any of the Group's Media channels (subject to our Privacy Policy). I do not want any photos or videos to be used.
For further information on this issue please see the 'Photographs and Videos' section of our 'Privacy Policy' which can be found on the 'Contact Us' page of our website.

I understand that if I change my mind, or we inadvertently publish material without parental permission, and it is brought to our attention by contacting the relevant Section Leaders, all images of the above named young person will be removed from all the Group's publications as soon as possible.

The Group cannot be held responsible for any images taken by other parties.
Prove that you are not a machine by Enter the text as shown *
By clicking on the Submit button you are not committing yourself to anything. The information that you have entered will only be used by the Scout Group (and only by the Scout Group) if / when your child starts attending the appropriate Section of the Group.
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166th (Mickleover) Derby Scout Group