Form to Be Returned to Or Posted to the Playhouse, 5-7 Artillery Street, Derry BT48 6RG

Form to be returned to or posted to the Playhouse, 5-7 Artillery Street, Derry BT48 6RG

Name Of Course : NB:OVER 16 YEAR OLDS ONLY
Start date:
Tutor:

Learner’s Name (please ensure it is clear as it will be on your certificate at the end of the course)

Surname:
Forename
Middle name (if applicable)

Learner’s Date of Birth (necessary for registration process)

Date Of Birth:

Learner’s Contact information

Address: / Post Code:
Email:
Telephone Number:

Photography Permission

Do you give permission for photographs/recordings to be taken during the course and their use for documentation and publicity? Yes/No:

Health and wellbeing and active participation support

You may wish to inform us of any illness/disability information (including medication) that you feel we should be aware of during your time on the programme. If you require support or assistance you should make the tutor and the course co-ordinator aware in confidence.
FOR COMPLETION AT OFFICE :Payment information (For paid courses only)
Course fee / Payment type (cash/cheque/bank card/creditcard) / Payment date / Further information
£60 Full cost
£45 concession rate* see below
*Evidence of one of the concession criteria below must be made to enrol you at the concession rate.
Concession category / Relevant concession category / Evidence (Attach to form)
Concession category if student is UK based:
Under 19 on 1/7/14/ or Student in FT F&H Education on 1/7/14; Working Tax credit;Aged 60+;Income support; Long Term incapacity.
Concession category if student is ROI based:
Under 19 on 1/7/14/ or Student in FT F&H Education on 1/7/14; Carer’s allowance; One Parent family payment; Widow or Widower non-contributory pension; unemployed or jobseekers allowance; disability allowance; supplementary welfare allowance;Pre-retirementallowance;Old age (Non-contributory) pension
Equal Opportunities information.

This information is required by our funders and partners. It is used only for statistical purposes and will be shared with them only for this reason. In each case, please tick the box that best describes you.

Gender -Please tick a box

Male
Female
Not Specified

Employment status:

Part time employed
Full time employed
Full time student
Registered unemployed –seeking work
Unwaged –not seeking work
Not specified

Disability

I have a learning difficulty or a disability
I do not have a learning difficulty or disability
No answer

Community Background

Protestant
Catholic
Other
Not known
No answer
Ethnicity: Please select from list below:
01 - White British
02 - White Irish
03 - Any other White Background
04 - Mixed White and Black Caribbean
05 - Mixed White and Black African
06 - Mixed White and Asian
07 - Any other Mixed Background
08 - Indian
09 - Pakistani
10 - Bangladeshi
11 - Any other Asian Background
12 - Caribbean
13 - African
14 - Any other Black Background
15 - Chinese
16 - Any Other Ethnic Group
99 - Not Stated

Siuan O Doherty, Head of Education, The Playhouse Theatre, 5-7 Artillery Street, Derry.Londonderry, BT48 6RG; ; 02871268027