Your Next Move: Sign up form for Street Dance classes at Parry Hall

Sign up form for Street Dance classes

Thanks for signing up to our Street Dance classes at Parry Hall in Tredworth, Gloucester. These classes will be taught by experienced Breaking (Breakdancing) teacher, Banxy - you can find out more about him on our website. Please complete this form, filling out all relevant sections. Your information will be kept safe and confidential. A parent / guardian must complete the form for under 18 year olds. If you need assistance to complete this form, or require it in a different format, please contact yournextmoveynm@outlook.com / 07842 591542.
PARTICIPANT INFORMATION
Your name / your child's name (the person who will be attending the class) *

First Name Last Name
Address *

Street Address

Street Address Line 2

City County

Postcode
Your / your child's date of birth *

Month Day Year
Date
Your age / your child's age (at the time of completing this form) *
Email (parent if under 18) *
example@example.com
Phone Number (parent if under 18) *
Please enter a valid phone number.
Your / your child's ethnicity (for monitoring & evaluation purposes, this information is kept confidential) *
EMERGENCY CONTACT INFORMATION
Name of emergency contact *

First Name Last Name
Relationship to you / your child *
Emergency contact telephone number *
Please enter a valid phone number.
Secondary emergency contact telephone number
Please enter a valid phone number.
MEDICAL INFORMATION
Doctor's name, surgery & telephone number *
Date of last tetanus injection *
Have you / has your child got a medical condition we need to know about? Please tell us what we need to know to keep you/your child safe and well?
Are there any actions we may need to take or signs we should look out for to give you / your child support?
Is there anything we may need to know that might affect your / your child’s safety or that of other participants?
Is there anything you / your child might have a problem with during the project that would be useful for us to know?
What should we do if there is a problem?
BEING SAFE, WELCOME AND ABLE TO TAKE PART
Do you / does your child identify as disabled? *

Yes No
Please tell us about anything we need to know to enable you / your child to enjoy taking part in our Street Dance Classes. This can include how we can ensure they feel included as well as access requirement during class.
Do you / does your child face challenges with your / their mental health, for example, anxiety, depression, low esteem? *

Yes No
Please tell us about anything we need to know to enable you / your child to enjoy taking part in our Street Dance Classes.
CLASS CHOICES

We are trying our best to book participants onto classes in advance. This is especially important to secure your / your child's place due to limited numbers to adhere to social distancing measures. If you cannot make a class / wish to attend an extra class in future, just get in touch with us and we'll update your class preferences.

Which classes would you like to attend? *

Parry Hall
17:00-17:30
Age 8-12

Parry Hall
17:45 - 18:15
Age 13-18

Thurs 8th Oct 2020

Thurs 15th Oct 2020

Thurs 22nd Oct 2020

Thurs 29th Oct 2020

Thurs 6th Nov 2020

Thurs 12th Nov 2020

Thurs 19th Nov 2020

Thurs 26th Nov 2020

Thurs 3rd Dec 2020

Thurs 10th Dec 2020

Thurs 17th Dec 2020

MEDIA CONSENT

You / your child may have the opportunity to feature in published photographs and/or filmed footage of performances at events. We would like to take photographs and video footage of participants for promotional, educational and funder reporting purposes. The images and filmed footage will be used by Your Next Move and may appear in our printed publications, in the media, on video and/or on our website or social media platforms. To comply with the General Data Protection Regulation (GDPR), we need your permission before we use any images of participants. Please answer questions 1 to 4 below, then sign and date the form where shown.
May we use images of you / your child in our printed promotional publications? *

Yes No
May we send out images of you / your child that may include you with our press releases? *

Yes No
May we use images that may include you / your child on our websites / online? *

Yes No
May we feature you in our promotional / educational videos? *

Yes No
May we use images / filmed footage of you in our reports to funders? *

Yes No
COVID-19 GUIDELINES AND PROCEDURES

Please read the Your Next Move Covid-19 guidelines for in studio classes, which can be found at yournextmove.org.uk/classes. Please also read and accept the following statements.
I understand that I should not attend class / should not bring my child to class if I am displaying symptoms of Covid-19 (new & persistent cough, high temperature, loss / change to sense of smell or taste) *

Tick to accept
I understand that I should not attend class / should not bring my child to class if I / they (or anyone in my/their household) have tested posted for Covid-19 *

Tick to accept
I have read and understood the Your Next Move Covid-19 guidelines for in studio classes. *

Tick to accept
FORM SUBMISSION
Signature *

Clear
Date form completed *

Month Day Year
Date
Would you like your details to be added to our database so we can let you know about similar opportunities in the future? We also run events and deliver other Hip Hop activities such as DJing, Graffiti Writing, MCing.

Yes please No thank you, I only want to be contacted about this class
Please verify that you are human *
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Sign up form for Street Dance classes

PARTICIPANT INFORMATION

EMERGENCY CONTACT INFORMATION

MEDICAL INFORMATION

BEING SAFE, WELCOME AND ABLE TO TAKE PART

CLASS CHOICES

MEDIA CONSENT

COVID-19 GUIDELINES AND PROCEDURES

FORM SUBMISSION