Participant Information Form
Please note this form must be filled out by someone over the age of 18 and will need to be filled per participant. If you have any questions or queries please contact us on engage@mayflower.org.uk
Activity Booked
*
Please Select
Junior Youth Theatre
Musical Youth Theatre Academic Yrs 7 - 9
Musical Youth Theatre Academic Yrs 10 -13
Drama Youth Theatre Academic Yrs 7 - 9
Drama Youth Theatre Academic Yrs 10 - 13
Junior Writers
Young Writers
Creative Writers
General Information
Booker's Name
*
First Name
Last Name
Main Correspondence's Email Address
*
example@example.com
Main Correspondence's Phone Number
*
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Participant Only Details
Please fill out the below boxes for the person taking part in the activity, please note it is one person per form.
Name
*
First Name
Last Name
Participant's chosen pronouns (e.g she/her, they/them etc.)
Date of Birth
*
/
Day
/
Month
Year
Date
Ethnic Origin
*
Please Select
Black African
Black Caribbean
Any other Black background
Arab
Bangladeshi
Chinese
Indian
Pakistani
Any other Asian background
Gypsy or Irish Traveller
Roma
White British
White Irish
White & Black African
White & Black Caribbean
White & Asian
Any other Mixed background
Any other Ethnic group
Prefer not to say
Not Known
Gender Identifies with
*
Female
Male
Non-Binary
Prefer not to say
Other
Pronouns
*
He/Him
She/Her
They/Them
Prefer not to say
Other
Postcode
*
Do you identify as Disabled?
*
Yes
No
Prefer not to say
Please disclose any medical conditions, disabilities, learning difficulties, access needs, and/or the taking any medication (this is to understand any support needs that you require during your time with us)
*
Are you happy for us to take photos/videos of your young person for promotional or historical purposes?
*
Yes
No
Other
Do you give permission to leave to the participant?
*
Yes
No
Monitoring Data
Please note the information below helps us to review our demographic of participants. If you wish not to answer these questions please select prefer not to say.
Do they receive FSM, Bursary, Scholarship, Universal Credit outside of Mayflower Theatre? (Please select all that apply) If any of the below are selected you may be eligible for a bursary.
Free School Meals
Bursary
Scholarship
Universal Credit
Other
Are you a carer?
*
Yes
No
Prefer not to say
Are you In Care/a Care Leaver?
*
Yes
No
Prefer not to say
Are you currently receiving support from CAMHS?
*
Yes
No
Prefer not to say
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Emergency Contact Details
These will be our point of contact in the event of an emergency.
Emergency Contact 1
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Emergency Contact 2
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
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Bursary Application
Please fill out the following information in order for us to process you Bursary Application.
Do you wish to apply for a Bursary?
*
Yes
No
Type of Household
*
Single Income
Dual Income
Other (please add additional comment to the box below)
Household Information
This section of the form should be filled out by the person where the participant resides
Main Resident
First Name
Last Name
Occupation of resident
*
Second Resident
First Name
Last Name
Occupation of second resident
Additional Comments
*
Please tick the box that best represents your total household income:
*
£0-£20,000
£20,001-£26,000
£26,001-£40,000
£40,001-£50,000
£50,001+
Does anyone in your household receive the following benefits? (tick all relevant boxes):
*
Child Tax Credit
Disability Living
Housing Benefit
Universal Credit
Working Tax Credit
None of the above
Are there any other financial circumstances that we should be made aware of?
How do you feel you/your child would benefit from the bursary?
*
I understand that the young person on this application may not be awarded a bursary and could be required to pay the full fee to participate in the activity. The information given in this application is true and accurate at the time of submission. In some circumstances Mayflower may need to verify the information you have provided.
*
Date
*
-
Day
-
Month
Year
Date
If any of your details change please inform us at engage@mayflower.org.uk
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Stay in touch!
Please confirm if you would you like to receive Mayflower Engage emails?
Please Select
Yes please!
I already receive these emails
No thank you
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