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LOLLIPOP YOUTH THEATRE MEMBERSHIP FORM
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Email
*
Your email
Full Name of Member
*
Your answer
Male/ Female
*
Male
Female
Other:
Address
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Name of School/ College
*
Your answer
Name of Parent/ Carer 1
*
Your answer
Contact Number of Parent/ Carer 1
*
Your answer
Relationship to Child
*
Your answer
Name of Parent/ Carer 2
*
Your answer
Contact Number of Parent/ Carer 2
*
Your answer
Relationship to Child
*
Your answer
Emergency Contact Name (This must be someone different to contact 1 & 2)
*
Your answer
Emergency Contact Number (This must be someone different to contact 1 & 2)
*
Your answer
Emergency Contact Relationship to Child (This must be someone different to contact 1 & 2)
*
Your answer
Name of Doctors Surgery
*
Your answer
Doctors Surgery Address
*
Your answer
Doctors Surgery Contact Number
*
Your answer
Does your child have any medical conditions?
*
Yes
No
Does your child have any allergies?
*
Yes
No
Please state any medical information we may need to know about your child (Including medicines, allergies etc.)
*
Your answer
If your child has to take medication during rehearsals or shows do you give permission for the first aider to give it to them?
*
Yes
No
If your child hurts themselves during rehearsals or shows do you give permission for the first aider to give them medical attention?
*
Yes
No
Photography/Video Permission Rehearsals- workshops and shows may be filmed or photographed for monitoring and general press and publicity purposes including use on our website and our public social media pages including Facebook.
I give permission for my child to be filmed or photographed.
*
Yes
No
Database Consent- I give permission for the contact details on this form to be included on the mailing list. Your details will not be passed on to anyone else.
*
Yes
No
Drop off and Collection for rehearsals Please state the name(s) of the adult(s) who will be dropping off and collecting your child each week
*
Your answer
For children over the age of 16 only: Do you give permission for your child to leave rehearsal on their own.
Yes
No
Clear selection
When paying the joining fee of £44 you will receive a Lollipop T-Shirt- Please state the T-Shirt size you require
*
Your answer
A copy of your responses will be emailed to the address you provided.
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