If you are referring a young person to our programme on their behalf, please use their 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
Mobile Number
Email 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)
Your name, role and organisation/service
Anything else you would like to tell us?
By signing up you agree to your photo/video to be taken for the purpose and promotion of the KICK programme. Photo's /video's may be posted on SDCP/ KICK Ireland social media platforms and website.This information will be stored on our data base and only used in the event of an emergency situation. By signing up, you agree that KICK, may collect, use and disclose your personal data as provided in this form, or (if applicable) as obtained by our organisation as a result of your participation, for the following purposes in accordance with the Data Protection Acts, and our data protection policy: a. The administration of your participation with KICK. Please contact us for further details on our data protection policy, including how you may access and correct your personal data or withdraw consent to the collection use or disclosure of your personal data.