Date:
Chapter 1 ‘The Limes’
Music Foundation Course
· Are you 19 -25? Yes No (Delete as appropriate)
If you have answered Yes : Please ensure you answer the following questions below.
1) Aged 19 year’s plus .
2) Is willing and committed to complete the 6 week programme.
3) Is active in his/her own learning.
4) Is able to speak and understand English. (Please contact us for clarification, if required.)
5) Have you any previous experience in music production? please explain below
6) What is your Music Genre….
5)6)
Music Foundation Course Referral Form
Personal Details:
First Name: …………………………………………………………….
Surname: …………………………………………………………….
Address (if applicable): …………………………………………………………….
…………………………………………………………….
Postcode: …………………………………………………………….
Telephone Number: …………………………………………………………….
Date of Birth: …………………………………… AGE ……………….
National Insurance Number: ......
Male / Female: …………………………………………………………….
Homeless project (if applicable): …………………………………………………………….
Special Educational Needs or Physical Limitations (Mobility needs, Dyslexia, Difficulty with basic skills) Y/N if Yes please give more details:
ESOL Level (if applicable) Entry 1 Entry 2 Entry 3 Level 1 Level 2
Current Education Details ______
Below is a list of modules you will be working with, what would you say was of the most interest to you? Or, are they all interesting?
Setting up midi connections Creating beats and DJ workshop
Midi & Audio Sampling Sound recording techniques
Editing & Mixing Music Business & Media
They are all interesting to me
To Be Completed By The Young Person Being Referred:
What do you think you will gain from completing This Music Foundation Course?
______
Young Person’s Consent:
I understand that this referral has been made and I am happy for this information to be passed on to Chapter 1 ‘The Limes’
Signed ______Print Name:______
Date ______
PLEASE COMPLETE EQUAL OPPORTUNITIES FORM AND RETURN TO
· Chapter 1 The Limes 76 Daisy Bank Rd, Victoria Park Longsight M14 5GL
· or Email to
EQUAL OPPORTUNITIES MONITORING FORM
Please help us to monitor equal opportunities by filling in this form. This will help us to make sure that the service we provide is accessible and open to all people who may need our service. If you have any questions about the form, please ask any member of staff, who will explain..
How would you describe yourself? (Please tick boxes)
Are you Female Male Trans Date of Birth ____ / ____ / ____
Ethnic Origin
African Caribbean Black British Other Black
Bangladeshi Indian Pakistani Other Asian
White British Irish Other White
White & Black African White & Asian White & Other Mixed
Black Caribbean
Chinese Other Rather not say
Please state if not on the list ______
Sexuality Disability
Lesbian I have a disability
Gay Man I do not have a disability
Heterosexual (straight) Rather not say
Don't know Refugee
Bisexual I am not a former Asylum Seeker
Rather not say I am a former Asylum Seeker
Rather not say
First Language ______Second Language ______
Are you homeless? Yes No Have you ever become homeless? Yes No
Are you pregnant? Yes No Do you have any children? Yes No
Have you ever been in care or lived with Foster Parents? Yes No
If yes, was this before you were 16? Yes No
After you were 16? Yes No
Are you still in care? Yes No
If yes, which Social Services Department were involved? ______
The Beat Drops Ear
From time to time we may take photographs of you whilst you are on the course at the Limes, these will be for educational or promotional purposes in any type of our media including it’s website. The photographs will not be used for profit, I understand that I will not be paid or rewarded for providing this authorisation.
I agree to having my picture taken
I do not agree to having my picture taken
Signed ………………………………………………..Date…………………………………..