Parental Consent Form |

Consent Form

1 Pupil Details

2 Parental Consent Form

Pupil Details
Pupil Name*
First Last
Date of Birth*
Date Format: DD slash MM slash YYYY
Current School*
Gender*
Instrument*
Current Severn Arts Ensemble(s) (if applicable)
Music Centre Tuition Details (if applicable)
We don't require details of school tuition
Current Level (approx)*
Grades do not necessarily need to have been taken
Account Holder Details
Account Holder Name*
Prefix First Last
Address*
Street Address Address Line 2 City County ZIP / Postal Code Country
Email*
Daytime Phone Number*
Mobile Phone Number
If different from above

Parental Consent
To be used where emergency medical treatment may need to be given during the course of a Severn Arts activity outside curriculum time.
1. 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.
2. I understand that the County Council accepts no liability other than that in respect of enforceable third party claims against members of its staff.
3. 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.
4. 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 Protection
Photography in Promotional Material*
I give permission for images of my child to be used in Severn Arts promotional materials.
- Accept
- Decline
Newspaper Articles*
I give permission for images and details (name, age) of my child to be used in newspaper articles.
- Accept
- Decline
Contact Details*
I give permission for contact details to be shared with other ensemble members for purposes of lift-sharing etc.
- Accept
- Decline
Medical Information
Any Medical Problems
None
Doctor's Name*
Doctor's Phone Number*
Doctor's Address
Street Address Address Line 2 City County Post Code

Consent Form

Pupil Details

Account Holder Details

Parental Consent

Child Protection and Data Protection

Medical Information