PACE Youth Arts -Saturday Registration Form

PACE Youth Arts

SATURDAY REGISTRATION FORM

Student Information
Student Information

Please complete one form per student
Students Full Name*

First NameLast Name
Age*
Birth Date*

DayMonthYear
Gender Identity*
Nationality*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Additional Information
Student Information Continued.
Please specify which class you would like to attend*

PACE TOTSPACE PRE-PRIMARYPACE PRIMARYPACE JUNIORSPACE YOUTH
Is there any other information that could enhance the students' experience which you would like to share

YESNO
If YES please give details:

PACE Scholarship
PACE Scholarship
Would you like to be considered for a PACE Scholarship? *please note, if you select yes, then you will be required to provide proof of benefits in order to be considered for a free placement.

YESNO
If YES, then please select which government support you are currently receiving:

Universal CreditLow income supportDLA (Disability Living Allowance)Other (please detail below)
If you selected "other" then please give more information below:
Please upload your proof of benefits here, you can request this via www.gov.uk

Cancelof

Parent/Carer Information
Approved Parent/Carers

Please list below and parents and/or carers that are approved to collect the student from PACE.
Approved #1
Full Name*

First NameLast Name
Relationship to child:*
Mobile Telephone*
Approved #2
Full Name

First NameLast Name
Relationship to child:
Mobile Telephone
Approved #3
Full Name

First NameLast Name
Relationship to child:
Mobile Telephone

Emergency Contacts
Emergency Contact #1
Full Name*

First NameLast Name
Relationship to child:*
Mobile Telephone*
Other Telephone:
E-mail address*
Home address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #2
Full Name*

First NameLast Name
Relationship to child:*
Mobile Telephone*
Other Telephone:
Email Address:
Home address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Carer Agreement
Parental Agreement
PACE aims to provide a safe and enjoyable experience for every child or young person.

To help us do this, please note the following important information.

• All questions on the consent form must be completed and signed by the parent

or carer before any child takes part.

• By signing the agreement, parents and carers are agreeing to pay all agreed fees to PACE Youth Arts prior to the child taking part. Failure to do so will result in the student losing their place in the programme.

• Parents and carers must ensure they notify us of any changes to the information given on the form.

• Parents and carers must make arrangements for children to be brought to and from the activity safely and on time. If a parent or carer is not able to collect their child, they need to let us know in advance who will be doing so.

• We cannot take responsibility for any damaged clothing and/or personal items during the activity.

• Parents and carers should ensure children have sufficient clothing, water and medication (where appropriate) for the duration of the activity.
I agree to (please tick)*

my child taking part in the stated activity - PACEPACE keeping a record of this form for health and safety reasonsany medical treatment that my child may need being given in an emergencymy child being filmed or photographed during the activity, with the possibility that these photographs/media recordings may be used for publications or marketing publicity. Note: See photo consent form above, if consent is not given, PACE will not use any images taken during the activity that contains the child/young person.
I understand that my child needs to follow the behaviour code and any safety rules so that PACE can keep them and other children safe.
Print Name of Parent/Guardian*
Signed Parent/Guardian*

Clear
Date*

DayMonthYear

Student Agreement
Student Agreement
I agree to (please tick)*

taking part in the activity - PACEtalk to Helen Duffy (Group Leader) if I am not comfortable at any time during the activity so they can help me or arrange for me to do something elsePACE keeping a record of this form so they have the information they need to keep me safe during the activityreceiving any emergency medical treatment that I may needbeing filmed or photographed during the activity. I understand that the photographs or film might be used to tell other people about what PACE does. Note: If I don’t agree to this, PACE will not use any images of me.
I understand that enjoying the activity and being safe means I need to follow the

behaviour code and safety rules.
Print Name of Student*
Signed Student*

Clear
Date*

DayMonthYear
Should be Empty:

PACE Youth Arts

Student Information

Medical History

Student Information Continued.

PACE Scholarship

Approved Parent/Carers

Approved #1

Approved #2

Approved #3

Emergency Contact #1

Emergency Contact #2

Parent/Guardian consent

Declaration of consent - parent / carer of child under 16

Parental Agreement

Student Agreement