Hoxton Hall Summer Holiday Programme 2019
In order to ensure the safety of all of our participants this form must be completed fully by all parents/guardians. By filling out this form you give permission for the London Borough of Hackney Youth Service to collect and store personal data about me and the activities which I participate in for monitoring purposes. I understand the data will be held in line with the Data Protection Act 1998 and subsequent updates and amendments.

Please fill out one form per participant.

Participants First Name *
Your answer
Participants Surname *
Your answer
Participants Age *
Your answer
Participants Gender *
Date Of Birth *
MM
/
DD
/
YYYY
Week One Performing Arts 7-10
Week One Poetry and Performance 11-19
Week Two Drama 7-10
Week Two Music video making (Blueprint Film 11-19)
Week Three Theatre Fun 7-10
Week Three Music Video Making (Blueprint) 11-19
Week Four Music 7-10
Week Four Forum Theatre (Odd Eyes Theatre) 11-19
Week Five Carnival 7-10
Week Five Carnival 11-19
Please give details of any participant medical condition or allergies that it would be useful for us to be aware of (e.g. diabetes, epilepsy, asthma, hay fever etc.)
Your answer
Please give details of any participant medical condition or allergies that it would be useful for us to be aware of (e.g. diabetes, epilepsy, asthma, hay fever etc.)
Your answer
Parent/Guardian Information
Your answer
Parent/Carer First Name *
Your answer
Surname *
Your answer
Mobile Number *
Your answer
Home Telephone Number *
Your answer
Email Address
Your answer
Postal Address Line 1
Your answer
Postal Address Line 2
Your answer
Postal Address Line 3
Your answer
Borough
Postcode *
Your answer
I consent to the participant receiving emergency medical or surgical procedures if necessary *
Are they allowed to go home by themselves? *
Are they allowed to go out for lunch by them selves? *
I give permission for my child to go outside to various locations such as parks as part of this project *
I consent to Hoxton Hall using images/video footage of the participant for promotional purposes, including flyers, posters, reports, press, media and on its own website *
Would you like to hear more about Hoxton Hall's work
How did you hear about Hoxton Hall?
Are you happy for us to share your details with similar organisations
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