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We have 18 free spaces for children in years 1-6 to come and try some street dance, led by Amy Boucher from Comfi-dance. They will learn some routines and then perform a 20-30 minute show for parents/carers/ grandparents etc. There will be a short break in the middle of each session for refreshments and a little think about champions and what makes someone a good person. All you need to do is copy and paste the form below and then email us the details to: stmarystjameslock@gmail.com and we will confirm your childs place. Places are starting to fill up and we will be doing more like this in the future. ConfiDANCE Children and Youth Consent Form. This personal information shall be kept securely and only used for ConfiDANCE related activities/ medical emergencies.
Name of group you are signing up to__________________________________________________________
Name of Child_____________________________________________________ Date of Birth_______________ Address__________________________________________________________ Postcode__________________ Home phone number________________________________ Mobile__________________________________ Email___________________________________________________ (Newsletters regularly sent electronically) Name of School_____________________________________________________________________________ Emergency contact name and number___________________________________________________________
Name of Doctor’s Surgery___________________________________________ Number___________________ If the need arises, can your child be given pain relief by club leaders? YES/ NO. Name of pain relief normally taken______________________________________________________________
Please list any allergies (ie foods, medicines, animals etc): ____________________________________________________________________________________________________________________________________________________________________________________ Any significant medical/ personal information? (ie special diet/ medical conditions): ____________________________________________________________________________________________________________________________________________________________________________________ Special medical treatment required (Please provide written medical instructions): ____________________________________________________________________________________________________________________________________________________________________________________
Do you give consent for your personal details to be used to contact you in relation to ConfiDANCE activities? (eg: session information/ change of dates etc) YES / NO
Do you Give permission for your child to attend activities/ events/ performances etc with ConfiDANCE Clubs that are held both on and off the premises? (you will always be notified with full details of these) YES / NO.
If it becomes necessary for your child to receive emergency dental or medical treatment and you cannot be contacted by telephone or any other means to authorise this, do you consent to any necessary treatment and authorise the group leader to sign any documents required by the hospital authorities? YES / NO.
Signature____________________(Parent/Carer) Printed____________________ Date___________
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- Please tick to indicate that you have signed the separate ConfiDANCE Media Consent form that has full details of our media and information sharing policy.