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Safeguarding Policy – Child Protection
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Health Information Questionnaire
Information supplied in this questionnaire provides a record of health and is used in assessing student’s suitability to attend our classes. These records will be stored in line with Surrey Youth Theatre’s GDPR policy for a maximum of 1 year.
Parent/ Guardian Name:
*
Student Name:
*
Emergency Contact Telephone Number One:
*
Emergency Contact Telephone Number Two:
Any change of student details e.g medical information or address:
Are you, or anyone in your household, experiencing any of the following symptoms at present (or have done in the last 14 days)?
A new continuous cough
*
Yes
No
A high temperature
*
Yes
No
A loss of, or change in, your normal sense of taste or smell
*
Yes
No
Have you recently travelled outside the UK?
*
Yes
No
If yes, please state which countries.
Please state your date(s) of travel outside of the UK
Have you knowingly encountered someone displaying the symptoms of COVID-19 or someone who has tested positive in the last 14 days?
*
Yes
No
Do you give permission for your information to be shared if required with the NHS Test and Trace to help stop the spread of Coronavirus?
*
Yes
No
I, the undersigned confirm that the above information is accurate to the best of my knowledge and hereby give consent for the information to be shared with Surrey Youth Theatre staff.
The student(s) for which I am responsible and I agree to comply with all hygiene procedures and rules while present at Surrey Youth Theatre classes and understand failure to follow these directives may result in termination of services provided with no refund.
I understand that if the student for which I am responsible, or anyone in our household develops any of the above symptoms, at any point during the term, the student will not attend class.
Date
*
Date Format: MM slash DD slash YYYY
Print Name
*
First
Last
Signature
*
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Workshop Form
Workshop Booking
Select Workshop
*
Select no. of children
*
1 Child
2 Children, Siblings
Show in a Week: “The Addams Family!” (1 Child)
Price:
£ 165.00
Show in a Week: “The Addams Family!” (2 Children, Siblings)
Price:
£ 300.00
Child 1 Details
Name
*
First
Last
Age
*
School Year
*
Date Of Birth
*
Date Format: MM slash DD slash YYYY
Medical Condition
Special requirements, allergies and/or medical conditions: (including sensitivities to plasters and face paint).
Child 2 Details
Name
*
First
Last
Age
*
School Year
*
Date Of Birth
*
Date Format: MM slash DD slash YYYY
Medical Condition
Special requirements, allergies and/or medical conditions: (including sensitivities to plasters and face paint).
Parent/Guardian Details
Parent/Guardian Name
*
First
Last
Phone
*
Email
*
Emergency contact number
*
Address
*
Street Address
Address Line 2
City
County
Post Code
Where did you hear about us?
Buy a Surrey Youth Theatre T-Shirt and/or Hoodie (Optional)
Select T-Shirt Size (£10.00 Each)
Age 5-6
Age 7-8
Age 9-11
Age 12-13
Age 14-15
Adult Small
Adult Medium
Adult Large
T-Shirt Age 5-6
Price:
£ 10.00
T-Shirt Age 7-8
Price:
£ 10.00
T-Shirt Age 9-11
Price:
£ 10.00
T-Shirt Age 12-13
Price:
£ 10.00
T-Shirt Age 14-15
Price:
£ 10.00
T-Shirt Adult Small
Price:
£ 10.00
T-Shirt Adult Medium
Price:
£ 10.00
T-Shirt Adult Large
Price:
£ 10.00
T-Shirt Quantity Age 5-6
*
Please enter a number from
1
to
10
.
T-Shirt Quantity Age 7-8
*
Please enter a number from
1
to
10
.
T-Shirt Quantity Age 9-11
*
Please enter a number from
1
to
10
.
T-Shirt Quantity Age 12-13
*
Please enter a number from
1
to
10
.
T-Shirt Quantity Age 14-15
*
Please enter a number from
1
to
10
.
T-Shirt Quantity Adult Small
*
Please enter a number from
1
to
10
.
T-Shirt Quantity Adult Medium
*
Please enter a number from
1
to
10
.
T-Shirt Quantity Adult Large
*
Please enter a number from
1
to
10
.
Select Hoodie Size (£25.00 Each)
Age 7-8
Age 9-11
Age 12-13
Age 14-15
Adult Small
Adult Medium
Adult Large
Adult Extra Large
Hoodie Age 7-8
Price:
£ 25.00
Hoodie Age 9-11
Price:
£ 25.00
Hoodie Age 12-13
Price:
£ 25.00
Hoodie Age 14-15
Price:
£ 25.00
Hoodie Adult Small
Price:
£ 25.00
Hoodie Adult Medium
Price:
£ 25.00
Hoodie Adult Large
Price:
£ 25.00
Hoodie Extra Large
Price:
£ 25.00
Hoodie Quantity Age 7-8
*
Please enter a number from
1
to
10
.
Hoodie Quantity Age 9-11
*
Please enter a number from
1
to
10
.
Hoodie Quantity Age 12-13
*
Please enter a number from
1
to
10
.
Hoodie Quantity Age 14-15
*
Please enter a number from
1
to
10
.
Hoodie Quantity Adult Small
*
Please enter a number from
1
to
10
.
Hoodie Quantity Adult Medium
*
Please enter a number from
1
to
10
.
Hoodie Quantity Adult Large
*
Please enter a number from
1
to
10
.
Hoodie Quantity Adult Extra Large
*
Please enter a number from
1
to
10
.
We occasionally take photographs of the students during classes, workshops and performances for publicity purposes. Please tick this box if you DO NOT wish for your child to be photographed.
In compliance with UK Data Protection, any information you provide here will be kept secure and treated confidentially. The data collected will only be used by Surrey Youth Theatre and will not be disclosed to any external sources without your prior consent. Please tick this box if you DO NOT wish to be added to our mailing list.
Our
Privacy Policy
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£ 0.00
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