Musicians in Focus Courses

Summer School 2017

Dates: 1 - 3 August 2017

SUMMER SCHOOL 2017 APPLICATION FORM

If you have any difficulty completing this form please email or call 029 20391430.

Name:

Address:

Telephone:

Mobile:

Email:

Emergency Contact Name:

Emergency Contact Number:

Date of Birth:

If under 18 years of age name of parent or guardian:

Do you have a computer?

Do you have a MIDI keyboard?

Instruments played and level: (on a scale of 1-5. 1 beginner, 5 very experienced)

Music Experience (on a scale of 1-5. 1 beginner, 5 very experienced)

Computer Experience (on a scale of 1-5. 1 beginner, 5 very experienced)

Do you prefer braille/large print/word file/text file for notes:

Please give details of any other specific support requirements:

Do you give your consent to share details of disability/medical support requirements with tutors?

Do you give your consent to administer first aid/call for medical assistance if necessary?

Do you give your consent for audio/visual recordings to be used by RWCMD and Musicians in Focus for educational and publicity purposes?

Please return this form to:

Patricia Keir

Royal Welsh College of Music Drama

Castle Grounds, Cathays Park,

Cardiff. CF10 3ER

I enclose a cheque/postal order for the £5 registration fee made payable to RWCMD

Signature: Date:

(Parent or guardian if under 18 years of age)

Monitoring

All information is kept anonymously.

Male/Female:

Age:

Nationality:

Country of Permanent Residence:

Ethnic Categories:

Please choose from the following typing X in the column following the category number.

Screen reader users note this is a table. TAB to move across the table, cursor keys to move up and down.

White – British / 11 / Other Black Background / 29 / Other Asian Background / 39
White – Irish / 12 / Asian or Asian British – Indian / 31 / Mixed – White and Black Caribbean / 41
White Other / 19 / Asian or Asian British – Pakistani / 32 / Mixed – White and Black African / 42
Black or Black British – Caribbean / 21 / Asian or Asian British – Bangladeshi / 33 / Mixed – White and Asian / 43
Black or Black British – African / 22 / Chinese or Other Ethnic Background – Chinese / 34 / Other Mixed Background / 49
Other Ethnic Background / 80 / Please give details

Disability Categories:

Please choose from the following typing X in the column following the category number.

Screen reader users note this is a table. TAB to move across the table, cursor keys to move up and down.

No disability / 00 / Deaf/hearing impaired / 03 / Mental health difficulties / 06
Dyslexia / 01 / Wheelchair user/mobility difficulties / 04 / Unseen disability / 07
Blind/partially sighted / 02 / Personal care support / 05 / Multiple disabilities / 08
Other disabilities / 09 / Please give details

If visually impaired, please give further details. How long have you been visually impaired?:

Are you registered blind or partially sighted, please state which:

Diagnosed condition if known:

Do you prefer braille/large print/audio recording/computer to read text:

Do you use visual aids, please give details:

Do you use assistive technology (screen reader, magnification) please give details:

Do you use mobility aids (symbol/long cane, guide dog, sat nav) please give details: