Maiden Lane Community Centre

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REGISTRATION FORM/INFORMATION

YP Full Name *

Date of birth *

YYYY

Gender *

Male

Female

Non-Binary

Other:

YP Mobile: *

YP Email:

PARENT/GUARDIAN DETAILS

Full Name *

Relationship to YP *

Home Address: *

Postcode *

Home Tel no.

Mobile Tel no. *

Email Address:

Work Tel no.

Work Email:

EMERGENCY CONTACT DETAILS

Full Name *

Relationship to YP *

Home Address: *

Home Tel no:

Mobile no: *

Email:

HEALTH CONTACT DETAILS

YP GP *

GP Address

PERMISSIONS

I confirm that I have parental responsibility for the child named on this registration form. I give my permission for photographs of my young person to be used on appropriate publications such as leaflets, newspapers or as part of an exhibition, or on a LB Camden or other partner’s websites. *

Yes

Print name below

Other:

HEALTH and DISABILITY

The Disability Discrimination Act (1995) defines a disabled person as someone who has a physical or mental impairment that has a substantial and long term adverse effect on his or her ability to carry out day to day activities.

Does your YP have a longstanding illness, medical condition or disability? *

Yes

Prefer not to say

If YES, please tick the boxes that describe your YP particular needs

Health or medical needs e.g. Allergies, Asthma

Cognitive or learning needs e.g. Dyslexia, Learning difficulties

Mental health difficulties e.g. Anxiety, Phobias

Sensory impairment e.g. hearing impairment, visual impairment

Speech language, Communication or Interaction needs and difficulties

Autistic spectrum disorder e.g. Asperger’s syndrome, autism

Physical needs and difficulties e.g. arthritis, cerebal palsy

Behaviour, Emotion and Social Development needs e.g. Attention Deficit (hyperactivity) disorder, conduct disorder, emotional and behavioural difficulties

Other:

Clear selection

MONITORING

Maiden Lane Community Centre aims to provide access to all YP, it is important for us to monitor who uses our services so please help us gather this information by completing the form below.

WHITE:

British

Irish

Greek or Greek Cypriot

Turkish or Turkish Cypriot

Albanian, excluding Kosovan

Kosovan

Other:

MIXED:

White and Black Caribbean

White and Black African

White and Asian

Other:

BLACK or BLACK BRITISH:

British

Congolese

Nigerian

Ghanaian

Kenyan

Caribbean

Somali

Other:

ASIAN or ASIAN BRITISH:

British

Indian

Pakistani

Bangladeshi

Other:

CHINESE or other ethnic Group:

British

Chinese

Other:

YP Country of Birth: *

FAITH / RELIGION

None

Muslim

Christian

Jewish

Hindu

Sikh

Buddist

Prefer not to say

Other:

Clear selection

GDPR STATEMENT *

I have access to a copy of MLCC’s Privacy Notice through MLCC’s website. I understand that the notice explains how my personal data will be processed used and stored and my rights in relation to this.

I consent to the use of this personal data in accordance with the terms of the Privacy Notice.

Required

Submit

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