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Guitar Circus educational programmes and resources for teachers
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First Name
Last Name
Address
Address (cont)
City
County
Postcode/Zip
Male/Female
MaleFemale
Date Of Birth (YYYY-MM-DD)
Student Phone Number
Student Email Address
Please upload a passport sized photo
Choose file
Do you have any MEDICAL CONDITIONS?
ASTHMAMIGRANEDIABETESEPILEPSYOTHER MEDICAL CONDITIONNONE
If so, please give any further medical details if necessary
Do you have any Special Educational Needs or Disabilities?
EDUCATIONALDISABILITIESNONE
If so, please give further details so we can support you
Do you have any DIETARY ALLERGIES?
NUTSDAIRYEGGGLUTENOTHER ALLERGYNONE
If so, please give any further dietary details if necessary
Do you have any MEDICAL ALLERGIES?
PENICILLINHAY FEVERECZEMAADHESIVE DRESSINGSOTHER MEDICAL ALLERGYNONE
If so, please give any further medical allergy details if necessary
Have you received a Tetanus injection within the last five years?
YESNO
Emergency Contact Details
Please give 2 members of family or friends we can contact in case of an emergency.
Emergency Contact Name 1
Emergency Contact Tel 1
Relationship to Student 1
Address if different from student
Emergency Contact Name 2
Emergency Contact Tel 2
Relationship to Student 2
Please give your G.P's contact details.
G.P's Name
G.P's Address
G.P's Contact Tel
Please give your DIETARY requirements
NONEVEGETARIANVEGANOTHER
Please give us any further physical, medical, dietary or allergy information you feel that we need to be aware of.
Parent/guardian must fill in this information on behalf of the student.
Parent Email Address
Please read the following permission requests carefully and indicate your preferences.
I give permission for GUITAR Circus to photograph and video my son/daughter and agree that GUITAR Circus can use these images (without identifying names attached) in future publicity if required.
I give permission for GUITAR Circus to hold my son/daughter details and data for their own exclusive use. These details will be held in accordance with 'General Data Protection Regulation (GDPR)' and will not be shared with any other organisation.
I give permission for GUITAR Circus personnel to seek professional medical treatment for my son/daughter in the event of an emergency and agree to my child receiving any treatment as considered necessary by the medical authorities present.
I give permission for my son/ daughter to receive first aid treatment from GUITAR Circus first aiders.
I give permission for my son/ daughter to be given the following “over-the-counter medication” by first aid staff should the need arise/if requested by my child:
Paracetamol YESNO
Ibuprofen YESNO
Antihistamine YESNO
I have read and agree to the course Rules, Terms & Conditions. Furthermore I agree to the GUITAR Circus staff acting ‘in loco parentis’ throughout the course.
I will inform the course co-ordinator if there are any changes to the medical or other information between completing this form and the commencement of the course.
If my son/daughter is exhibiting a high temperature, a new persistent cough, a loss or change in taste or smell or any other symptoms which may be suggestive of a COVID-19 infection, then he/she will not attend rehearsals and I shall endeavour to inform Guitar Circus to that effect through the absence form
If my son/daughter has been asked to isolate or has been in contact with someone who may have COVID-19 then he/she will not attend rehearsals and I shall endeavour to inform Guitar Circus to that effect through the absence form
Please select your ethicity from the correct dropdown box, or select the box indicating that your preference not to answer.
WHITE —Please choose an option—English, Welsh, Scottish, Northern Irish or BritishIrishGypsy or Irish TravellerAny other white background
MIXED or MULTIPLE ETHNIC GROUPS —Please choose an option—White and Black CaribbeanWhite and Black AfricanWhite and AsianAny other mixed or multiple ethnic background
ASIAN or ASIAN BRITISH —Please choose an option—IndianPakistaniBangladeshiChineseAny other Asian background
BLACK, AFRICAN, CARIBBEAN or BLACK BRITISH GROUPS —Please choose an option—AfricanCaribbeanAny other Black, African or Caribbean background
OTHER ETHNIC GROUP —Please choose an option—ArabAny other ethnic group
PREFER NOT TO SAY —Please choose an option—Select
Please answer the math question to show you are not a robot: 12+48= Thank you!
