Lift Off! |

Lift Off! FREE music group for all

Step 1 of 4 - Pupil details

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Pupil details
Pupil name*
First Last
Date of birth*
DD slash MM slash YYYY
School year group*
This group is for school aged children (reception and above)
School
Instrumental music teacher
Instrument*
Current level*

Please note the following:-
- Should Lift Off! music group you have selected not be viable due to insufficient numbers, an alternative group will be offered. This may mean that the meeting day/time of the new group is different from your first choice.
Lift Off! music groups
Please select the Lift Off! music group you would like to take part in*
- Bromsgrove Lift Off!: Wednesday, 5 - 5.45pm
- Kidderminster Lift Off!: Thursday, 5.30 - 6.15pm
- Malvern Lift Off!: Monday, 4.15 - 5pm
- Worcester Lift Off!: Wednesday, 5 - 5.45pm

Parent/carer details
Name*
Prefix First Last
Primary email address*
This must belong to the parent/carer and be the email that will be used for the Lift Off! information and all communication from Severn Arts.
Secondary email address*
Daytime phone number*
Mobile phone number
If different from above
Emergency contact details
Name of emergency contact 1*
First Last
Mobile phone number of emergency contact 1*
Name of emergency contact 2*
First Last
Mobile phone number of emergency contact 2*

Parent/carer agreement
Parent/Carer agreement*
I give permission for my child to participate in a Severn Arts outside of school activity.
- Confirm
I confirm that I have parental/legal responsibility over the child*
- Confirm
Parental consent
Emergency medical treatment*
Parental consent is required by Severn Arts should emergency medical treatment be needed whilst your child is participating in a Severn Arts activity. Please read our Parental Consent Agreement and confirm your consent below.
- Yes - I consent to medical treatment
- No - I do not consent to medical treatment
Filming and photography*
From time to time we may wish to take photographs or film children taking part in Severn Arts activities. See our Filming and Photography Consent for full details. Please confirm your consent below.
- Yes - I consent to filming and photography
- No - I do not consent to filming and photography
Contact details*
Contact details may be shared with other group members for purposes of lift-sharing etc. Please confirm your consent below.
- Yes - I consent to the sharing of contact details
- No - I do not consent to the sharing of contact details
Child licensing
The participation of children (who are below school leaving age - year 11 and below) in performances is governed by the Children and Young Persons Act 1963, sections 37 and 39, and The Children (Performances and Activities) (England) Regulations 2014. To comply with the current legislation, we need to confirm the age of your child.
Was your child born after 1st September 2005?*
- Yes
- No
I confirm that my child is fit to take part in Severn Arts performances and that his/her health will not suffer as a result.*
- Confirm
Medical information
Medical details
Please give details of any medical problems your child has, including both physical and mental health.
Doctor's name*
Doctor's phone number*
Doctor's address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
Your privacy
Data consent*
The information you enter into this form will be collected and stored by Severn Arts. Please tick the tick box below to confirm you understand.
- I understand
We will always store your personal details securely. We’ll use them to provide the service that you have requested, and communicate with you in the way(s) that you have agreed to. You can change your mind at any time by contacting us at [email protected] and by clicking the unsubscribe link in the Mailchimp emails you receive from us. Your data may also be used for analysis purposes, to help us provide the best service possible. For full details see our Privacy Policy By clicking 'Yes' below to subscribe to our updates you agree that we may use your information in accordance with these terms.
Keeping in touch*
We’d love to keep you posted with our news, events and activities. Would you like to receive updates from us?
- Yes
- No
I am particularly interested in:
- Music
- Arts
- Festivals
- Cultural education updates for young people
- Receiving the Arts Newsletter for practitioners