Name of Entrant

2017

Name of entrant
Name of poem / rap
Date of birth
Name of School
Home Address
(please include postcode)
Telephone Number
Email Address
I hereby agree to my poem/rap video being uploaded to the Poetry Society’s YouTube channel and understand that it will be viewed by the general public. I also understand that I am an entrant to the competition and that my video will be judged accordingly and also, that I may be contacted to perform live. I agree to being contacted for interview by the media.
Signed ______Date ______
If you are under 16, you will need a parent or guardian to sign below.
Signed ______Date ______
(parent or guardian)
Relationship to entrant ______
Telephone number ______
This form also gives my permission for my poem/ rap to be placed by The Poetry Society where they see fit, as long as I am fully credited for it. I understand that the Poetry Society may also contact me for press interviews, photo calls and television / radio interviews where appropriate.

Please email scanned forms to or post to SLAMbassadors UK, The Poetry Society, 22 Betterton Street, London WC2H 9BX.

Equal Opportunities Monitoring Form

We gather information provided by entrants to SLAMbassadors UK to enable us to monitor and carry out our activities as required by our funders, eg Arts Council England, and in accord with the charitable aims of The Poetry Society.

The questions below about gender/ethnicity/age are not compulsory, but they do help us to build a better statistical picture of our audience for reporting and administrative purposes.

This form will be anonymized and will not be kept with your entry form.

1. Date of birth
______/ 5. How would you describe your ethnic background?
White
English/Welsh/Scottish/ Northern Irish/British
Irish
Gypsy or Irish Traveler
Any other White background
Mixed / multiple ethnic groups
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed/Multiple ethnic background
Asian / Asian British
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
Black / African / Caribbean / Black British
African
Caribbean
Any other Black/African/Caribbean background
Other ethnic group
Arab
Any other ethnic group please specify
______
Prefer not to say
2. How would you describe your gender?
Male
Female
Other please specify ______
Prefer not to say
Preferred pronoun please specify ______
3. Do you consider yourself to have a disability?
Visual impairment
Hearing impairment/Deaf
Physical disabilities
Cognitive or learning disabilities
Mental health condition
Other long term/chronic conditions
Other please specify ______
Prefer not to say
4. What is your sexual orientation?
Bisexual
Gay Man
Lesbian
Heterosexual/Straight
Other please specify ______
Prefer not to say

Please note that personal information provided by or about you will be treated confidentially, and that measures are in place to prevent unauthorised disclosure.