Stirling Council
Children, Young People and Education
Parental Consent Form 2015
1
PLEASE CIRCLE APPROPRIATE GROUP/S
Youth Orchestra
2
Wind Band
String Orchestra
Vocal Ensemble
Guitar Ensemble
PERSONAL DETAILS
(All information given will be treated in the strictest confidence)
Name
_______________________________________________________________
Date of birth
______________________________
Address
_______________________________________________________________
Male
Female
_______________________________________________________________
Phone no
_______________________________________________________________
Parent/Carer’s Email address)
_____________________________________________
(For use in connection with concert/rehearsals only)
School
____________________________________Class____________
Instrument____________________
Instrumental Tutor_________________
I agree to the pupil named above taking part in this activity and I acknowledge the need for
obedience and responsible behaviour on his/her part.
3
MEDICAL
Does this pupil suffer from any conditions requiring medical treatment, and/or medication?
Yes
No
If yes please give details: _____________________________________________________
Has pupil received an anti-tetanus injection in the last five years?
Yes
No
Other:
Please give details ___________________________________________________________
I undertake to inform the leader in charge as soon as possible of any changes in medical
circumstances.
I agree to my child’s image being taken as part of the group in rehearsal or performance and
used in promotional material for Stirling Council only.
Please circle
YES
NO
I am/am not available to help with Secondary Music Days on 11 and 12 November.
4
FEES
I enclose fee
£10.00/£5.00 (one fee per pupil no matter how many groups
the pupil is involved with)
I wish to apply for a reduction in fees as I am in receipt of (tick as appropriate)
Free School Meals
5
Clothing Grant
On secondary music days only, some pupils may not require to be transported back to their
school (eg if you live close to the Albert Halls or if it is more convenient to collect them from
the Albert Halls rather than from their school etc.) If your child will be not be returning on the
bus please complete and sign here.
I agree to my child leaving the venue on his/her own after the rehearsals on
Wednesday/Thursday (please circle)
Signed Parent/Carer __________________________________________________________
6
DECLARATION
I agree to the above named pupil receiving emergency medical treatment including
anaesthetic as considered necessary by the medical authorities present.
I may be contacted at the following numbers
Mother’s mobile:
______________________________________
Father’s mobile:
______________________________________
If not available please contact:
Name
______________________________________
Relation to pupil
______________________________________
Address
______________________________________
______________________________________
Phone no
______________________________________
Name and address of Family Doctor:
Name
_______________________________________
Address
_______________________________________
_______________________________________
Phone no:
_______________________________________
Return this consent form (all parts completed) to:
Lesley McEwan, Senior Music Tutor, Children, Young People and Education, Stirling Council,
Municipal Buidlings, 8-10 Corn Exchange Road, Stirling FK8 2HU.
Date______________
Signed________________________________ (Parent/Carer)
Please indicate