Applicants Full Name/Members Full Name: (required)

Parent/Guardians Full Name: (required)

Applicant/Members DOB:(required)

Applicant/Member attending School and which year:(required)

Does your Child have any of the following? You can select multiple options.

AsthmaAny AllergiesAny Skin ConditionsHearing ImpairmentVisual ImpairmentAny Learning DisabilityAny Physical DisabilityAny Medical Conditions?Taking Any Regular Medication(s)?Been to see or had a referral to a hospital consultant in the last 6 months?

If Yes to any of the above please give details here, if No, please state No:

*As defined within section 3 of the Children Act 1989, ‘parental responsibility’ means all of the rights, duties, powers, responsibilities and authority which by law a parent of a child has in relation to the child and his property.

I confirm that I have parental responsibility for this child.

Please click to give permission to BSMTC Juniors Ltd permission to take photographs and/or video your child.

YesNo

I grant Bishops Stortford Academy of Performing Arts full rights to use the images resulting from the photography/video filming, and any reproductions or adaptations of the images for fundraising, publicity or other purposes to help achieve the group’s aims. This might include (but is not limited to), the right to use them in their printed and online publicity, social media, press releases and funding applications.

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Print Name (required)

Print Todays Date (required)

Parent / Guardian Home Address (required)

Parent / Guardian Email (required)

Parent / Guardian Telephone (required)

Doctors Name and Address (required)

Doctors Email

Doctors Telephone (required)

How did you hear about us? (required)

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Additional Info

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Contact Permission

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