Phoenix Dance Theatre
Summer School Booking Form
27th - 31st July 2015
If you need help or advice when completing this form, please do not hesitate to contact our Access and
Education team on 0113 236 8130 or email emily.labhart@phoenixdancetheatre.co.uk
PERSONAL DETAILS (PARTICIPANT)
Full Name: Click here to enter text.
Date of Birth: Click here to enter a date.
Address:
Postcode: Click here to enter text.
Gender: Click here to enter text.
Do you (the participant) have any medical conditions e.g asthma? If yes, please specify:
Click here to enter text.
Previous dance experience:
☐ None
☐ Some
☐ Dances regularly
ADDITIONAL NEEDS
☐ No known disability
☐ Blind/partially sighted
☐ Deaf/hearing impairment
☐ Wheelchair user/mobility difficulties
☐ Personal care support
☐ Mental health difficulties
☐ Multiple disabilities
☐ Autistic Spectrum Disorder
☐ Learning difficulties (e.g dyslexia)
☐Other
☐ I do not wish to give this information
ETHNIC ORIGIN – completion of this section is optional
☐ Asian/Asian British – Bangladeshi
☐ Mixed – White and Black African
☐ Asian/Asian British – Indian
☐ Mixed – White and Black Caribbean
☐ Asian/Asian British – Pakistani
☐ Mixed – other mixed background
☐ Asian/Asian British – other Asian background
☐ White - British
☐ Black/Black British – African
☐ White – Irish
☐ Black/Black British – Caribbean
☐ White – other mixed background
☐ Black/Black British – other Black background
☐ Any other
☐ Chinese
☐ Not known/not provided
PARENT/GUARDIAN/CARER DETAILS
Full Name: Click here to enter text.
Relationship to participant: Click here to enter text.
Address: Click here to enter text.
Postcode: Click here to enter text.
Home Telephone: Click here to enter text.
Mobile Telephone: Click here to enter text.
Work Telephone: Click here to enter text.
ALTERNATIVE EMERGENCY CONTACT DETAILS
Full Name: Click here to enter text.
Relationship to participant: Click here to enter text.
Address: Click here to enter text.
Postcode: Click here to enter text.
Home Telephone: Click here to enter text.
Mobile Telephone: Click here to enter text.
Work Telephone: Click here to enter text.
PHOTOGRAPHY PERMISSION
For purposes of documentation, monitoring, and evaluation, it is necessary to take photos of activities at Phoenix
Dance Theatre. Photos will only be taken by a professional photographer with all relevant DBS certification.
Images will be used for printed publicity and possibly for the Phoenix Dance Theatre website. We will not use
images without your consent as indicated below (please tick box).
☐ I consent to my child’s image being taken and used in Phoenix Dance Theatre publicity
CHILD PROTECTION
Dance is a physical activity involving movement with a gymnastic quality. It may involve contact between teacher
and student, for example during corrections to aid safe practice. There will be times where student-to-student
partner contact will take place. All contact will however be kept to a minimum and used only with consent.
DECLARATION – to be completed by parent/legal guardian.
I (full name) Click here to enter text. agree to (participant name) Click here to enter text. taking
part in Phoenix Dance Theatre Summer School.
I will inform Phoenix Dance Theatre as soon as possible of any changes to the above information.
Signed: Click here to enter text.
Date: Click here to enter a date.
Please return to:
Access and Education Department
Phoenix Dance Theatre, Quarry Hill, Leeds, LS2 7PA
0113 236 8130 / emily.labhart@phoenixdancetheatre.co.uk