Youth Theatre Emergency Contact Form
Child’s Details
Full name:
Address
Date of birth:
Postcode:
Daytime telephone no:
Email:
Parent(s) Guardian(s) Information
1) Name:
Relationship to child:
Home no:
Email:
2) Name:
Relationship to child:
Home no:
Email:
Mobile no:
Mobile no:
Additional Information
Yes
No
Does your child have a disability,
medical condition we should know about
or learning support need?
Does your child require any special
requirements for the workshop?
If yes to any of the above, please provide details below:
In the event of an emergency do you give consent for your child to receive treatment?
YES/NO
Signature
Parent/Guardian Signature:
Name (in block capitals)
Date:
Gateway Card
The Hampshire County Council Gateway Card is for children and
young people who have a disability and/or additional needs and may
require support to participate in leisure and recreation activities are
between 0 to 19 years old live in Hampshire and/or attend a school in
Hampshire (excluding Portsmouth, Southampton and the Isle of
Wight as they have similar schemes). The Gateway Card is free and
will give you access to activities, play schemes and buddy schemes
available through our short breaks programme.
Does your child have a Gateway Card? If so please write the number below.
_________________________________
To find out more please visit: http://www3.hants.gov.uk/gatewaycard
Mailing List
Occasionally Fluid Motion Theatre Company sends out newsletters via email that have
information on upcoming events, performances and general company news.
Would you like to join our mailing list?
Yes/No
If yes state preferred email address: _________________________________________
How we use the information you give us
Information you give Fluid Motion Theatre Company will be used by us to tell you about any of our services and to
give you information on issues relevant to the arts and community sector. Fluid Motion Theatre Company will
communicate with you by telephone, letter, email, or in any other reasonable way. You can ask for a copy of the
information we hold about you and your organisation, and if the information isn’t accurate, you can ask us to correct
it. If you do not want to receive letters, emails and telephone calls from us in the future, please tell us in writing. We
will NEVER pass your contact details on to salespeople, or to private organisations.
If you have any questions about how Fluid Motion Theatre Company will use information about your organisation,
please contact us.
Fluid Motion Theatre Company
The Orchard
White Hart Lane
Basingstoke
RG21 4AF
01256 423836
info@fluidmotiontheatre.co.uk
www.fluidmotiontheatre.co.uk