GLUE Sign-up Form
Child's Details
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Other
Please list what workshop(s) your child would like to participate in (Music, Young Writers, Drama and Steelpan):
*
Parent/Carer Details
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Emergency Contact Details
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Collections
Is your child authorized to go home without an adult?
*
Yes
No
Please list the names of any adults (other than the parent/carer and emergency contacts stated above) who are authorized to collect your child. Individuals must be over the age of 16.
Health/Personal Matters
Doctor's Name
*
First Name
Last Name
Doctor's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Doctor's Telephone Number
*
-
Area Code
Phone Number
Please list any dietary restrictions below:
*
Please list any allergies below:
*
Please list any medical conditions below:
*
Please list any disabilities below:
*
Is there anything else you feel we should be aware of?
Consent
I agree to my child taking part in GLUE workshops at The Tabernacle W11:
*
Yes
I confirm to the best of my knowledge that my child does not suffer from any medical conditions other than those listed above:
*
Yes
No
I understand that the Club or Organizers accept no responsibility for loss, damage or injury caused by or during attendance on any of the organized activities except where such loss, damage or injury can be shown to result directly from the negligence of The Tabernacle.
*
Yes
I confirm that only I and/or any of the above named are authorized to pick-up my child at the end of workshops. If my child is permitted to go home without an adult, I confirm that they will be able to do so in a responsible and safe manner.
*
Yes
No
I agree to allow The Tabernaclew11 Ltd. to take photographs of the child(ren) in my charge and grant permission for these to be used by the Tabernacle and its project partners* to promote The Tabernacle in publications, press articles, promotional material and websites, exclusively for non-profit making purposes.
*
Yes
Signature
*
Clear
Submit
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