Emergency Contact Sheet

Polka Theatre Drama Workshops

Emergency Contact Sheet

Name of workshop______

Name of Child ______Date of Birth ______

Please note that if your child is too young for the workshop then we do reserve the right to refuse admittance to the workshop.

Name of Parent/Carer______

Address ______

London Borough ______

School or Nursery Attended______

Email ______

Home phone number ______

Emergency Phone Number (Mobile/work) ______

Other contact numbers ______

Name 2 alternative adults who are authorised to collect your child:

Is there any other information that will help us to provide the best tuition for your Child?

______

For all holiday workshops, we provide juice and biscuits, please inform us of any allergies we should be aware of:

______

Please indicate whether you are happy to give consent for your child to be videoed/photographed.

I hereby consent for my child to be photographed or videoed by Polka Theatre and or other parents/carers of children attending workshops. I understand that the photographs may be displayed at the theatre or used in marketing material and printed in publications, but only in connection with Polka Theatre. My child will not be named in any such photographs.

Signed Parent/Carer ______Date______

If you do not give your permission, then please provide a detailed description of your child in particular what they are wearing so that they can be deleted out of any photograph they appear in.

______

Monitoring Form

In order for us to ensure that we provide equality of opportunity in all that we do, it is necessary for us to record information about everyone who takes part in our activities. This information will be used for Polka’s own monitoring purposes only and will not be passed on to any third party.

Sex

Male Female

Ethnic Background

WhiteBritish Asian or Asian British Indian

Irish Bangladeshi

Eastern European Pakistani

Other White Background Other Asian background

...... ……......

MixedWhite & Black Caribbean Black or Black British Caribbean

White & Black African African

White & Asian Other Black background

Other mixed background ...... Other background …………………………….

Chinese

Is English your child’s second language?Yes No

Religion

Please tick the box that closely matches the religion of your child

AgnosticHindu Rastafarian

AtheistHumanist Sikh

Baha’i Jain Zoroastrian

Buddhist Jewish None

Christian Muslim Other

Does your child have a disability or special needs?Yes No

If yes, you may elaborate here: ......

......