Dance Registration Form - CHESS Cluster - Breeze

REGISTRATION FORM – Space2 Summer Activity 2012
(Chess ) Dance 30 July – 3 August
Name: _____________________________________________________________
Address: ____________________________________
Postcode: _____________________
Tel: ________________________
Mob: _______________________
Date of Birth: ______________________
Email: ___________________________________
Medication currently being taken _________________________________________________
Other relevant medical information ________________________________________________
Next of Kin
Name: ______________________________ Relationship to you: _______________________
Address: _______________________________________ Postcode: _____________________
Day Tel: ______________________
Night Tel: ________________________
Mob: __________________________
I understand and agree:
1. That all the above information is correct
2. That I/my child can receive emergency medical treatment as considered necessary by an
appropriately qualified person
3. That I will bring and pick my child up from rehearsals
4. I give permission for my child to make their own way to and from the activity
PARTICIPANT NAME (Please print): _______________________________________
SIGNATURE: _________________________ DATE: _________________
(Parent/Carer to sign if participant is under 18)
Space2 Leeds, registered charity no. 1105268
Company no. 4930452. Registered Offices Leeds Media Centre, 21 Savile Mount LS7 3HZ

Space2 Leeds – Space2 Summer Activity 2012
(Chess ) Dance 30 July – 3 August
Parental Consent Form for use of images of children for photography, interviews, film recording
and using images and voices
Child’s name:
____________________________________________________
Sometimes, we may take photographs of your child whilst attending our provision. We may use these images in
publicity material, in other printed publications that we may produce or on websites or to submit as evidence of high
quality provision to support funding applications etc. We may also make video or webcam recordings and voice
recordings of your child for promotional use, for information, evaluation or other educational use and for website use.
From time to time we may be visited by the media who will take photographs or film footage of your child as part of a
project or event. Your child may appear in these images, which may appear in local or national newspapers (including
their websites) or on televised news programmes.
To comply with the Data Protection Act 1998, we need your permission before we can photograph or make any
recordings of your child. Please answer the questions below then sign and date the form and return to one of our
Facilitators.
Please place a in
I give permission for Space2 to use my child’s photograph in publicity
material in other printed publications that Space2 produce or to submit as
evidence of high quality provision to support funding applications etc
I give permission for Space2 to involve my child as part of any external
media coverage eg. local or national newspaper coverage and understand
that I may appear in local or national newspapers (including their websites)
or on televised news programmes
I give permission for Space2 to record my child’s image and/or voice for
use on Space2 websites, podcasts, CDs and DVDs and partners’ websites
I give permission for Space2 to use my child’s image and/or voice for use
on third party websites, including Youtube and Flickr
The above consents will apply throughout the world and be for an indefinite period
the appropriate box
Yes No
Signed: _____________________________ Date: ___________________
Address:
___________________________________________________________
___________________________________________________________
Postcode:
_________________________________________________________________
Space2 Leeds, registered charity no. 1105268
Company no. 4930452. Registered Offices Leeds Media Centre, 21 Savile Mount LS7 3HZ

MONITORING FORM - (Chess ) Dance 30 July – 3 August
Space2 Summer Activity 2012
Below we are requesting information to help us monitor this project .You can help us by
filling in the information below, but you do not have to do so. Thank you.
MALE
FEMALE
AGE 0 – 12 13 – 18 19 – 40 41- 65 65+
ETHNIC ORIGIN (please tick):
White Other White Irish Indian
Pakistani Bangladeshi Other Asian Caribbean
African Other Black Mixed parentage Other European
Not stated
Other
Refugee or
Asylum seeker Gypsy / Traveller Homeless
Are you experiencing or recovering from mental health problems?
Do you have learning disabilities?
Do you have a physical impairment?
Thank you
Space2 Leeds, registered charity no. 1105268
Company no. 4930452. Registered Offices Leeds Media Centre, 21 Savile Mount LS7 3HZ