Consent Form 1 Pupil Details2 Parental Consent Form Pupil DetailsPupil Name* First Last Date of Birth* Date Format: DD slash MM slash YYYY Current School*Gender*MaleFemaleInstrument*Current Severn Arts Ensemble(s) (if applicable)Music Centre Tuition Details (if applicable)We don't require details of school tuitionCurrent Level (approx)*Grades do not necessarily need to have been takenBeginnerGrade 1Grade 2Grade 3Grade 4Grade 5Grade 6Grade 7Grade 8DiplomaAccount Holder DetailsAccount Holder Name* MrMrsMissMsDrProf.Rev. Prefix First Last Address* Street Address Address Line 2 City County ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Daytime Phone Number*Mobile Phone NumberIf different from above Parental ConsentTo be used where emergency medical treatment may need to be given during the course of a Severn Arts activity outside curriculum time. I agree that my son/daughter may take part in all Severn Arts activities including rehearsals and concerts by Music Centre groups and Central Ensembles at various venues outlined in Music Centre brochures and the Severn Arts website. Such activities may also include trips to festivals, workshops, residential and day courses, and competitions that may not appear in brochures but notified separately by letter. I understand that the County Council accepts no liability other than that in respect of enforceable third party claims against members of its staff. I further understand that if I so wish, I may take out personal accident insurance covering my son/daughter against accidents or loss, which may occur through no fault of any supervising staff, and that such insurance is my responsibility. I agree to medical and dental treatment being given to my son/daughter if required, including the administration of a general anaesthetic and to surgical operations in the case of emergency, in accordance with the recommendation of a qualified medical practitioner. Agreement* I agree to the above Child Protection and Data ProtectionPhotography in Promotional Material*I give permission for images of my child to be used in Severn Arts promotional materials.AcceptDeclineNewspaper Articles*I give permission for images and details (name, age) of my child to be used in newspaper articles.AcceptDeclineContact Details*I give permission for contact details to be shared with other ensemble members for purposes of lift-sharing etc.AcceptDeclineMedical InformationAny Medical ProblemsNoneDoctor's Name*Doctor's Phone Number*Doctor's Address Street Address Address Line 2 City County Post Code