Synthesis Project — Parental Permissions Form for Participants Under 18
The Synthesis Project is run by Southampton Music Hub, a partnership of organisations, which is led by Southampton Music Services, which is part of Southampton City Council.

Southampton Music Services is requesting parental permissions for participants under the age of 18, to take part in the Synthesis Project.

Unless additional consent is given, the email address you provide will only be used contact you about your child's participation in the Synthesis Project.

Email address *
Parental Contact Information
Please provide details of the parent or guardian completing this form, and their emergency contact information.

Unless additional consent is given, this information will only be used to contact you about your child's participation in the Synthesis Project.

Name of parent or guardian *
Please provide the name of the parent or guardian completing this form.
Your answer
Emergency contact number *
Please provide the emergency contact number for the parent or guardian named above — this should usually be a mobile phone number.
Your answer
Additional emergency contact name
You may also provide an additional emergency contact name, if needed.
Your answer
Additional emergency contact number
You may also provide the emergency contact number, if needed — this should usually be a mobile phone number.
Your answer
Synthesis Participant
Please provide details for the participant in the Synthesis Project.
Participant's name *
Please provide the name of the participant in the Synthesis Project.
Your answer
Participant's date of birth *
Please provide the date of birth for the participant in the Synthesis Project.
MM
/
DD
/
YYYY
Challenging circumstances
The Synthesis Project aims to help participants face and overcome the challenges they may have in their lives by participating in, and benefiting from, music-making with others. Please use the space below to provide any information that might help the team better understand the challenges the participant named above may face, and any existing strategies that are in place that may help the team in supporting their journey. If you would prefer to discuss this over the phone, please use the space below to suggest days and times that a member of the team could call you on the contact number provided above.
Your answer
Participation Information
The Synthesis Project will help participants to improve their composition and performance skills through making electronic music in iPad clubs, bands and orchestras. Participants will also be supported to develop their self-confidence and inter-personal skills through working collaboratively with others.
Participation agreement *
I give permission for the participant named above to take part in music-making activities as part of the Synthesis Project.
Required
Progress monitoring and evaluation *
I give permission for the participant named above to be included in progress monitoring and evaluation processes, as part of the Synthesis Project, and for anonymised and collectivised data about the named participant to appear in private and public publications. Unless additional permissions are given, participant names will not be published alongside recordings of their work.
Required
Additional progress monitoring and evaluation permissions
To celebrate individual achievements as part of the Synthesis Project, Southampton Music Services is also requesting permission to publish the name of the participant named above alongside descriptions and records of their achievements, including printed and online publicity, social media, press releases, evaluation reports and funding applications.
Audio recording permissions *
I give permission for the participant named above to be included in audio recordings of their work as part of the Synthesis Project, and for these recordings to appear in private and public publications. Unless additional permissions are given, participant names will not be published alongside recordings of their work.
Required
Additional audio recording permissions
To celebrate individual achievements as part of the Synthesis Project, Southampton Music Services is also requesting permission to publish the name of the participant named above alongside recordings of their work, including printed and online publicity, social media, press releases, evaluation reports and funding applications.
Photographic records *
I understand that photographic and video records will be used to document participants' progress throughout the Synthesis Project, and I give permission for the participant named above to be included in photographs and video recordings which will be only be used for internal monitoring within the project.
Required
Photographic Permissions Statement
Southampton Music Services is requesting permission to take photographs and/or video of the participant named above.

The resulting images/videos may be used by Southampton Music Services, both internally and publicly, for publicity and fundraising, including printed and online publicity, social media, press releases and funding applications.

Southampton Music Services is the lead partner for Southampton Music Hub and may share the images/videos with its hub partners. A list of hub partners is available online (www.southamptonmusichub.org/about), or on request.

You can change these permissions at any time, however, please be aware, that where images have already been shared publicly (in print and online) that removal of these images may not be possible.

For those over the age of 16, personal photographic permissions should also be given: https://goo.gl/forms/dpb6DoUoIpSmxObn2

Photographic permissions agreement
Additional photographic permissions
To celebrate individual achievements as part of the Synthesis Project, Southampton Music Services is also requesting permission to publish the name of the participant named above alongside images/videos.
Photographs at performances
As part of the Synthesis Project, participants will be invited to take part in performances of their music. At times, these performances may take place in public spaces where photography by the audience cannot be controlled. Please use the space below to provide any information that might help the team plan and prepare for public performances to help maximise the involvement of the participant named above. If you would prefer to discuss this over the phone, please use the space below to suggest days and times that a member of the team could call you on the contact number provided above.
Your answer
Privacy Statement
Southampton Music Hub is led by Southampton Music Services which is part of Southampton City Council.

Southampton City Council is collecting this information in order to perform this service or function, and if further information is needed in order to do so, you may be contacted using the details provided. In performing this service, the Council may be required to share your information with other organisations or departments, but it will only do so when it is necessary in order for the service to be provided.

The Council may also share personal information for the purposes of the prevention, investigation, detection, or prosecution of criminal offences, but will not share personal information, or use it for this, or any other purpose, unless provided for by law. The information provided will be held on file and may also be stored electronically.

More detailed information about the Council’s handling of your personal data can be found in its privacy policy, available online (http://www.southampton.gov.uk/privacy), or on request.

Privacy agreement *
Required
Email newsletters
To receive updates, news and events from Southampton Music Hub, you can sign up to the Southampton Music Hub email newsletter — you can unsubscribe from these emails at any time.
Declaration Statement
I agree to the content of this form and confirm that all the details provided are correct. I confirm that I am the legal parent or guardian of the named individual.
Declaration agreement *
Required
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Southampton Music Hub (Southampton City Council). Report Abuse - Terms of Service