Brent Young Cultural Ambassador Enrolment Form 2014
First Name: / Last Name:
Date of Birth: / Gender: (please tick)
Male …… Female……
Other…..
Address
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Postcode……………………… Borough ………………………………………………………..
Home Phone / Mobile
Email:
Emergency Contact:
Name (and relationship) ………………………………………………….
Phone …………………………………………………………………………………………………
We want to ensure our projects/spaces are equally accessible for everyone. Please provide any additional details/requirements that could help us to ensure this (eg. physical assistance, equipment, materials in different format)
…………………………………………………………………………………………………………………………………………………………………………………………………………………………
Are you currently studying towards an Arts Award (please tick)?
Yes….. No…..
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Are you currently? (please tick):
1) Studying ……
2) Working full time
3) Working part time ……
4) Studying and working……
5) Unemployed (unregistered) ……
6) Unemployed (registered) ……
7) Other (please specify below)…...
Name of school or college (if studying)
……………………………………………… / Studying (please tick):
1) Pre-GCSE
2) GCSE
3) A/AS Levels ……
4) NVQ ……
5) BTEC ……
6) Degree ……
7) Other (please specify below)……
Do you have any medical conditions that we should be aware of? (e.g. epilepsy, diabetes?)
………………………………………………………………………………………………………………………………………………………………………………………………………………………
Have you enrolled on any Brent Council Projects or courses in the past?
YES / NO ?
If yes, which one(s)? ……………………………………………………………………………………………………………………………………………………………………………………………………
When you enrol on this programme, we’ll automatically contact you about similar opportunities by email. If you would NOT like to receive this information, please let us know below (please tick):
Would you like to hear about other events at Brent Council?
Yes …… No ……
Complete if you are over 16
I …………………………………………………………. (please enter your name) certify that the information set out in this YCA enrolment form is, to the best of my knowledge, accurate and complete.
In addition, I understand that whilst attending this programme there may be circumstances where my image(s) in whatever format, including but not limited to photographs, video footage and images used on Brent Council’s website may be used by Brent Council for marketing and promotional purposes.
I hereby give my consent for image(s) to be used YES / NO ?
If any of the information set out in this student enrolment form changes, I will notify Brent Council of any changes.
Signed……………………………………………………..
Date …………………………………….
Consent to attend – to be completed by your parent/guardian if you are 16 or under
I…………………………..…………………………………………………………………
(parent or guardian) of ……………………………………………………………………
hereby consent to the processing of the participant’s personal and/or sensitive personal data in accordance with the DPA for the purposes of their participation in this Brent Council Programme.
In addition, I understand that whilst attending this Brent Council Programme (including use of Brent Council facilities), there may be circumstances where image(s) of the participant in whatever format, including but not limited to photographs, video footage and images used on the Brent Council website may be used by Brent Council for marketing and promotional purposes.
I hereby give my consent for image(s) of the participant to be used YES / NO ?
If any of the information relating to the Participant changes, I will notify Brent Council of any changes.
Name ………………..…………………………………………………………………………………
Signed……………………………..
Date…………………………………………………………..
Please email to
Or post to: Brent Council Civic Centre, Exhibition Way, Wembley, Middlesex, HA9 0FJ
T: 020 8937 3117 or 020 8937 3603
www.brent.gov.uk/arts
www.bmyvoice.org.uk