YOUNG ACTORS STUDIO

TASTER WORKSHOPS

26 – August 2015

Places are allocated on a first-come, first-served basis, so please submit your enrolment formas soon as possible.THE DEADLINE FOR ENROLMENT IS FRIDAY21ST AUGUST 2015

Applicant’s Personal Details (to be completed by parent/carer if applicant is UNDER 18years)

Full Name
Date of birth / Male/Female
Address
Postcode / Telephone number
Mobile number / Email address
Full names of Parents/Carers
Emergency contact name and number(s)

Essential Information (to be completed by parent/carer if applicant is UNDER 18years)

Under the Data Protection Act 1998, we are required to ask for consent to disclose personal information.
Please indicate below whether you give consent for us to: / We are required to ask your permission for us to administer first aid and/or telephone an ambulance in the event of an emergency.
Please indicate below whether you give consent for us to:
Provide your telephone number to tutors, if required / YES/NO / Administer first-aid to you (or your son/daughter) if required / YES/NO
Use your (or your son/daughter’s) image in RWCMDpublicity material / YES/NO / Telephone an ambulance for you (or your son/daughter) in an emergency / YES/NO
Provide details of specific needs as disclosed below to relevant tutors / YES/NO
Provide factors affecting health as disclosed in questions 1 to 7 below to relevant tutors / YES/NO
Use statistical information anonymously for monitoring purposes / YES/NO
Allow your son/daughter to leave the Pembrokeshire College premises during breaks / YES/NO
Nationality / Country of permanent residence(UK residents, please specify England, Wales, Scotland, Northern Ireland, Channel Islands or Isle of Man as appropriate)

Ethnic Classification(for anonymous statistical analysis)
I would describe myself/son/daughter as (please tick as applicable):

White - British /  / White – Irish /  / White Other /  / Black or Black British – Caribbean / 
Black or Black British – African /  / Other Black Background /  / Asian or Asian British – Indian /  / Asian or Asian British – Pakistani / 
Asian or Asian British – Bangladeshi /  / Chinese or Other Ethnic Background – Chinese /  / Other Asian Background /  / Mixed – White and Black Caribbean / 
Mixed – White and Black African /  / Mixed – White and Asian /  / Other Mixed Background /  / Other Ethnic Background / 

Disabilities (please tick if applicable)

No disability /  / Deaf/hearing impaired /  / Mental health difficulties /  / Other disabilities / 
Dyslexia /  / Wheelchair user/mobility difficulties /  / Unseen disability / 
Blind/partially sighted /  / Personal care support /  / Multiple disabilities / 

Health Information – please give details of:

1 / Any fractures or broken bones currently causing any weakness/discomfort
2 / Any injuries such as sprains, strains or dislocations currently causing any weakness/discomfort
3 / Any major illnesses that you wish us to know about
4 / Any condition such as asthma or persistent hay fever that you wish us to know about
5 / Any drug allergies
6 / Any medication taken on a regular basis
7 / Any other factor affecting you(or your son/daughter’s) general health that you feel would be useful for us to know
8 / Please give details of any specific needs requiring additional equipment/support.
I confirm that the information provided on this form is correct to the best of my knowledge and that I consent for my information to be used for the purposes listed above.
Signature (to be signed by parent/carer if applicant under 18)
______ / Date
___/___/_____