ICE North East Ambassador Registration Form
Title
First name
Last name
Previous name (maiden etc)
Date of Birth:
Organisation/Company/University:
ICE Membership No:
Institution (if not an ICE member)
Telephone:
Mobile Phone:
Email:
ICE holds all members’ addresses and other contact details on its database but providing the information above will
allow us to ensure that your details are current and correct.
Do you have access to a vehicle?
Yes / No
Do you hold a current Disclosure and Barring Service (DBS) Check?
Yes / No / Pending
If so, please supply your Disclosure number ONLY
Number:
To get a free DBS check via STEM you can sign up at https://db.stemnet.org.uk/register/ambassador
Please tick all of the following which apply:
I am willing to undertake activities in:
I live in:
Northumberland
Northumberland
Tyne & Wear
Tyne & Wear
Durham
Durham
Teesside
Teesside
*Important* Please read the following statements and indicate your agreement by signing the form where
indicated.
While I am an ICE Ambassador, I agree to support at LEAST TWO activities in the first year and at least ONE in
each subsequent year.
I agree to my information being held in the ICE Ambassador database. I understand that this information will be
treated in strict confidence. It will only be used for the purpose of administration and operations connected with
ICE activities and will not be shared with third parties.
Ambassador Signature:
Date:
Please return to: icene@ice.org.uk, or mail to: ICE North East, 2.08 Drummond Building, Newcastle University,
Claremont Road. Newcastle upon Tyne, NE1 7RU
Registered charity number 210252
Charity registered in Scotland number SC038629