New Lodge Arts - Senior Youth Theatre
Under 18's (to be completed by Parent/Guardian)

Wednesday  - Senior Youth Theatre 4th  - 6th  Year
with Debra Hill

Times: 7.30pm - 9.00pm 

Venue: Girdwood Community Hub

Beginning: Wednesday 17th April - Wednesday 12th June 2024

The cost is £18 for this term or £2 per class. 
Please pay via Paypal on the link provided on this page. 
OR pay the £2 each week at the class. 
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Email *
Participant Personal Details
Please provide the details of your child below

Full Name of Child *
Date of Birth of Child *
Address *
Postcode *
Religion *
Please provide details of parent/guardian below

Full Name *
Relationship to Young Person *
Address (if different from above)
Email Address
Home/Mobile Telephone Number *Please ensure you provide an accurate phone number as a member of staff will contact you to ensure you have completed this form* *
Emergency Contact Details
Please provide emergency contact details that are different to the parent guardian who can be contacted, if the parent/guardian is unavailable, details above
Name *
Relationship to young person *
Home/Mobile Telephone Number *
Address *
Participant Medical Details
Please provide any medical details of the young person below

Doctors Name *
Surgery *
Surgery Address *
Phone Number *
Does your child have any additional needs? *
If yes, please give details below
Does Your Child Have Any Allergies or Ongoing Illnesses? If yes give details below *
If yes, please give details below
Please tick boxes below to indicate how your child will arrive at the youth centre at the arranged times (please note that if this should change you will need to complete a new form): *
Please Provide The Details Of The Person/Persons Authorised To Collect Your Child. Please Provide Name & Contact Number
Health & Safety Statements
Please read the health and safety statements below and tick if you want to give permission for these

I give my consent for my child taking part in an activity/event facilitated by New Lodge Arts *
I give my consent for my child to participate on trips and activities at various venues accompanied by New Lodge Arts Staff/Volunteers *
I am aware and consent to my child to appear in any photography/film relating to New Lodge Arts activity/event.  I consent for the photographs/film being used in material promoting New Lodge Arts including the Organisation’s web site and social media. *
I give my consent for the leader in charge to seek medical help from a trained person or professional body should my child be hurt or take ill during an Activity with New Lodge Arts *
I understand that a member of staff who suspects that a child in his/her care may have been abused or neglected has a duty to report this to the designated officer within the organisation who will contact social services. *
New Lodge Arts is a subsidiary of Ashton Community Trust. New Lodge Arts and Ashton Community Trust are committed to protection and respecting your child’s information. New Lodge Arts and Ashton Community Trust give assurances that: • Any processing of personal information relating to your child is carried in compliance with the General Data Protection Regulation (GDPR) and the Data Protection Act 2018 (DPA). • Any staff handling personal data are subject to a duty of confidentiality and comply with the obligations under the GDPR and DPA. • Appropriate technical and organisational security measures to ensure compliance with the GDPR and DPA. • The obligations under the GDPR and DPA are met in relation to allowing data subjects to exercise their rights under the legislation. • Report data breaches to the Information Commissioner (if legally required) within 72 hours and co-operate with the ICO as necessary. New Lodge Arts is managed from our office at: Ashton Centre, 5 Churchill Street, Belfast BT15 2BP. If you have any questions in relation to this Privacy Notice or the personal information we have about your child please contact the Data Protection Representative for Ashton Community Trust: Ciara Rea on 02890 322289 Ext: 3118 or alternatively email at view our full Privacy Notice look on our website at  *
I am aware of and give my consent for my child’s personal information being held on Ashton Community Trust and New Lodge Arts member’s database and understand that all information held on my child will be stored in line with the regulations set out by the General Data Protection Regulation 2018 and will only be accessed by New Lodge Arts and Ashton Community Trust Staff. *
I am aware and consent to staff members contacting my child where appropriate about the programme through official social media such as Facebook and Messenger *
I am aware and consent to a staff member who has a full drivers licence and have the appropriate insurance to transport my child when necessary to and from certain venues *
If your child is involved with any health professionals, such as Health Visitor, Social Worker, Occupational Health or Other please can you inform Anne Delaney, Arts Programme & Operations Manager. *
Permission can only be given by the individual/s that has parental responsibility for the child. Parental responsibility is defined as: The natural Mother always has parental responsibility. The Natural father gains paternal responsibility: • If he’s married to the mother at the time of the child’s birth. • If he marries the mother after the child’s birth, he has parental responsibility if he lives in Northern Ireland at the time of the marriage. • An unmarried father has parental responsibility if he’s named, or becomes named, on the child’s birth certificate (from 15 April 2002).    
By completing and submitting this form you are accepting responsibility that you have provided full and accurate information that is required as a parent/guardian of the young person. *
Name Of Parent/Guardian Completing Form * *
Date Form Completed *
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