Licence Form- Parent Section

Licence Application Form- Parent Section

Part 2: Information to be provided by the applicant in relation to the child
Please provide a picture of your child's BIRTH CERTIFICATE (a phone picture is fine)

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1) Childs Name
2)Child's home address:
3)Child's date of birth:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
4)Name and address of the school the child currently attends: OR If the child is not attending school, the name and address of the child’s private teacher:
If this is your childs first job go straight to question 10

Questions 5&6 are only relevent if the child has moved house, to a different local authority in the last 12 months and has already had licences issued or refused at their old address. If not go to question 7
5)Details of each licence in relation to the child granted during the twelve months preceding the date of the application by any local authority, or in Scotland, any education authority, other than the licensing authority to which this application is made, stating -
a) The name of the authority:
ie. London Bought of Havering
b) The date the licence was granted:
c) The dates and nature of performances or activities:
N/A
6)Details of each application in relation to the child for a licence refused by any other authority in the last 12 months, other than the licensing authority to which this application is made, stating -
a) The name of the local authority or education authority:
ie. London Bought of Havering
b) The reasons (if known) for the refusal to grant a licence:
N/A
7)Details of any performances for which a licence was not required in which the child took part during the previous 12 months, stating -
a) The date of the performance:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
b) The number of days of performance:
c) The title of the performance:
d) The name and address of the person responsible for the production:
8) Dates (if any) on which the child has been absent from school during the twelve months preceding the date of the application by reason of taking part in a performance or activity:
Zero
9)Amount of any monies earned by the child during the last twelve months, stating whether the monies earned were in respect of performances or activities for which a licence was granted or a performance for which a licence was not required:
Medical declaration to be completed by child’s parent
Does your child have: (answer yes or no)

If yes please provide details including any treatment or medication:
Asthma
Any allergies
Any skin conditions
Hearing impairment
Visual impairment
Any learning disability
Any physical disability
Any medical conditions?
Taking any regular medication(s)?
Been to see or had a referral to a hospital consultant in the last 6 months?
I confirm that I have parental responsibility for this child.(Signature of parent):
Print Name:
Postal Address (if different from child)
Parents Email Address
Parents Telephone No.
Date:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty:

Licence Application Form- Parent Section