Southend YMCA All-In-Music Application

Southend YMCA - All In Music Application Form

We provide a range of opportunities for young people seeking to develop their musical ability, or looking to increase their confidence and social skills through music. All In Music is a National Lottery and Youth Music funded project aimed at mentoring and supporting young people using music. We can work with individuals aged 11-25 years as a part of this programme.
Referee Details

Please complete if you are referring on behalf of a young person
Referral Organisation (if applicable):
Referee Name:

First NameLast Name
Phone Number:

Area CodePhone Number
E-mail address:
example@example.com
How did you hear about All In Music?
Details of the Young Person

(Person being referred)
Name of young person:*

First NameLast Name
Date of Birth:*

DayMonthYear
Address of Young Person:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Landline Phone Number:
Mobile Phone Number:
E-mail Address:
Ethnicity:*
Musical Interests (please select one or more):*

Bass GuitarDrumsGuitar (Electric or Acoustic)Music Technology & Beat-MakingMusic Theory / CompositionPianoRappingSingingSongwriting / Lyric WritingOther
Tuition Preference:*

GroupOne-to-OneEither
Please select all current availability:*

Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PMThursday AMThursday PMFriday AMFriday PM
Any further information related to your availability?
Please provide us with your earliest/latest possible timeslots in regards to selected availability above.
Parent/Guardian Information

Please provide the following information of Parent/Guardian of the Young Person.
Name of Parent/Guardian:

First NameLast Name
Relationship to Young Person:
Landline Phone Number (Of Parent/Guardian):
Mobile Phone (Of Parent/Guardian):
Referral Information

Why does the referrer or young person want to access All In Music?
Reason for Referral:*
(Please note that this project is aimed at providing opportunities for disadvantaged young people, for example: those at risk of exclusion, those suffering from physical/mental health problems, financial deprivation or with criminal/substance misuse issues. Please indicate how the person fits within the project criteria and what you’d hope that they would gain from involvement in the project).
Health/Medical Considerations (if applicable):
Please state any medical or health considerations that are known. This would include any physical, psychological or learning difficulties the young person may have:
Are there any identified risks associated with this applicant?
(Southend YMCA embrace and promote diversity and would not discriminate against any young person on the grounds of sex, gender, ability, disability or history. However, all applicants will be subject to proactive assessments in relation to suitability and any associated risks disclosed or identified. Part of this process will include contact with the referring organisation) Are there any identified risks associated with this applicant? Please include criminal convictions, medical issues and any problems with drugs and/or alcohol.
Declaration for Participation

If the young person is under 18, they may need an adult to go through this section to make sure they fully understand it. As far as I am aware, the information I have given about myself is true and correct - providing false information could result in removal from any Southend YMCA (SYMCA) programmes. For SYMCA to assess your application we may need to check the information on your application with external agencies and partners who could be, but not limited to; parent/carer; Social Services; Probation Service, Youth Offending Team; YPDAT; schools/colleges; other relevant persons or organisations. We will also need to retain the contact information given above for both the participant and the referee. Please sign or write your name below to show that you understand that SYMCA may need to obtain information to process your application and that you give consent for us to do this.
Name: *

First NameLast Name
Declaration for participation:*

I agree and consent to the above Declaration for Participation
SYMCA Dress Code Policy

Young people attending SYMCA and its youth projects, should be dressed in manner that is comfortable and weather appropriate but remembering that this is a place of learning and work, that we have frequent visitors to the site and that students in their appearance and behaviour, both at SYMCA and when travelling to and from SYMCA are representatives of SYMCA and have a duty to help us maintain our positive reputation. SYMCA is a place of learning and work and we expect attendees to be dressed appropriately. A few specific issues that we would ask for your support with are: Shorts/Skirts/Dresses should be close to knee length and smart-casual. T-shirts should display no inappropriate wording, symbols or logos. No crop tops/strapless tops/anything too revealing or low/high cut. No transparent, ‘cut away’ tops or low riding jeans (underwear should not be visible). If our requests regarding dress codes are not met, we reserve the right to refuse entry to our premises and events and to cancel appointments/sessions/young people’s participation in events at a moment’s notice. This applies to both SYMCA events and off-site events where young people are representing the SYMCA.
Name: *

First NameLast Name
Agreement to SYMCA Dress Code Policy:*

I have read, agree and consent to following the above SYMCA Dress Code Policy
Media Consent & Release

As part of All-in-Music we regularly take photographs, interviews and some video/audio footage of the participants taking part in activities and events that we hold. We do this as a means of recording and reporting to funding bodies and partner agencies about how All In Music is delivering its aims, to use for future publicity of the programme and most importantly, to record the fun times that the young people have whilst with All In Music. The participant’s image in still or recorded form, voice or quoted interview may be given to the media (print, video/radio/TV broadcast, online, etc.) to be included in news or feature articles about Southend YMCA, Youth Music, or other organisations that we work with. This consent form also shows that you agree that any compositions or works created are jointly owned by the student and SYMCA and therefore can be used by SYMCA for its own purposes. Any commercial gain or royalties earned on works created with All In Music are shared 50/50. All media used will be processed in accordance with the Data Protection Act 1998 and may be used more than once without restriction and without compensation. If you are aged 18+ and self-referring, you may sign yourself to confirm your agreement with the above terms. If you are under 18 and self-referring you will need a parent/guardian to sign on your behalf. If you are referring on behalf of a participant, by signing you are confirming that you have disclosed the above information to the participant and that they agree with these terms.
Name:*

First NameLast Name
I, the participant and/or or legal representative for the young person; agree to the media consent/release above:*

Agree and give permission.Disagree and do not give permission.
By using this form, our services and submitting your information, you agree to the Southend YMCA Privacy and Cookie Policy. (READ HERE).
Southend YMCA Privacy and Cookie Policy Consent:*

I have read and I agree to the above policy.
Thanks for completing this form! We'll be in touch as soon as possible.

If you have any questions regarding your referral, please email allinmusic@southendymca.org.uk or call the All In Music team (Davey or Tom) on 01702 301301.
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Southend YMCA - All In Music Application Form

Referee Details

Details of the Young Person

Parent/Guardian Information

Referral Information

Declaration for Participation

SYMCA Dress Code Policy

Media Consent & Release

Thanks for completing this form! We'll be in touch as soon as possible.