Your teenagers details

Please register your interest to participate in a KICK programme in your area. This information will be used to demonstrate a need for more KICK programmes in other areas.
First Name
Last Name
Date of Birth
Phone Number
Your Email Address
Your Address
School Name (if applicable)
School Address
13. How did you hear about the programme?
14. Why do you think this young person should do the KICK programme? (can click multiple boxes)
Anything else you would like to tell us?