Chime sign up form

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Chime sign up form

If you need to discuss this form, or need help completing it, please email gavin.leonard@theatreroyalwakefield.co.uk

Participant's name *

Participant's date of birth *

YYYY

Contact email *

Primary contact phone number *

Name of primary contact *

Relationship of primary contact to participant *

Address *

Second emergency contact number

Name of second emergency contact

Relationship of second emergency contact to participant

We have places available that offer financial support to those that wouldn’t otherwise be able to take part. Would you need help with the cost of these sessions? (Sessions are £5 per week) *

Yes

Please tick any or all of the below that apply to the participant

I have a learning disability and/or autism

I have a physical disability

I have limited mobility

I need to bring a helper / support worker with me

I need written materials in a certain format (large-type, coloured paper etc.)

I have a medical condition you need to be aware of

I have allergies you need to be aware of

Please provide ALL relevant support information below; this will allow our team to provide the best possible support to our participants.

Do we have your permission to take and use your child’s photo and to capture them on film for documentation and/or publicity such as leaflets, social media, posters, and videos at Theatre Royal Wakefield? By giving your permission we can use the image or footage from the date you have provided permission and up until two years after the project finishes, but we will always seek your permission if we would like to publish it again after this period. You can request that we cease to use any image featuring the participant at any point. *

Yes

I have read the above details and give permission for my child / young person to take part in Chime. By ticking below, I give my permission for Theatre Royal Wakefield to process the information I have provided in this form and during the course of the activity for the purposes of: communicating with me; delivering and promoting Participation activities; keeping written registers; providing appropriate support; to ensure that all activities are fully inclusive and all access needs have been considered; contacting me in the event of an emergency. The information will be stored securely and only be accessible to designated persons that need it for the purposes outlined above unless in the event of a safeguarding concern. Theatre Royal Wakefield takes child safety very seriously and operates within guidelines detailed in its safeguarding and child protection policy, which can be found here: www.theatreroyalwakefield.co.uk/take-part/safeguarding-policy Our Privacy Policy can be found here: www.theatreroyalwakefield.co.uk/privacy-policy. Theatre Royal Wakefield has a number of staff trained in Emergency First Aid at work and by ticking below you are giving consent for us, where necessary, to carry out first aid on your child or young person. *

Yes

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