Bennu Youth Dance Company

NO BOUNDS | ENROLMENT FORM

SESSIONS Please select which session you would like to attend:

☐ HOVINGHAM PRIMARY SCHOOL | Hovingham Avenue, Leeds, LS8 3QY Tuesdays Ages - 8-12 | 5pm-6:15pm

☐ KALA SANGHAM ARTS CENTRE | St Peter’s House,1 Forster Square, Bradford, BD1 4TY Thursdays Ages - 7-11 | 5pm-6pm Ages - 12-18 | 6pm-7.30pm

Participant Contact Information Name

Address

Postcode

Date of birth Name of participant’s School/College Contact Number

Contact Email

Do you suffer from any YES NO medical conditions?

If YES please specify:

Emergency Contact Details 1 Name Relationship to participant * please ensure this is a number that can be contacted during the Contact Number session

Contact Email Emergency Contact Details 2 Name Relationship to participant * please ensure this is a number that can be contacted during the Contact Number session.

Contact Email

ADDITIONAL NEEDS ☐ No known disability ☐ Multiple disabilities ☐ Blind/partially sighted ☐ Autistic Spectrum Disorder ☐ Deaf/hearing impairment ☐ Learning difficulties (e.g dyslexia) ☐ Wheelchair user/mobility difficulties ☐ Other ☐ Personal care support ☐ I do not wish to give this information ☐ Mental health difficulties

ETHNIC ORIGIN ☐ Asian/Asian British – Bangladeshi ☐ Mixed – White and Black African ☐ Asian/Asian British – Indian ☐ Mixed – White and Black Caribbean ☐ Asian/Asian British – Pakistani ☐ Mixed – other mixed background ☐ Asian/Asian British – other Asian background ☐ White - British ☐ Black/Black British – African ☐ White – Irish ☐ Black/Black British – Caribbean ☐ White – other mixed background ☐ Black/Black British – other Black background ☐ Any other ☐ Chinese ☐ Not known/not provided

Further Information

Do you have any previous dance experience?

If YES please provide details.

How did you hear about NO BOUNDS?

PHOTOGRAPHY & FILM PERMISSION For purposes of documentation, monitoring and evaluation, it is necessary to take photos / videos of activities throughout the course of the project. Photos / videos will only be taken by a professional photographer with all relevant DBS certification. Images will be used for printed publicity and possibly for the Phoenix Dance Theatre website and social media activities. We will not use images without your consent as indicated below (please tick box):

☐ I give photo / film consent ☐ I do not give photo / film consent

DECLARATION

To be completed by parent / legal guardian:

I ______(name of parent / legal guardian) agree to______(name of participant) taking part in this project.

I will inform Phoenix Dance Theatre as soon as possible of any changes in medical or other circumstances.

Signed: ______Date: ______

Please complete & return this form to:

sophie.wyatt @phoenixdancetheatre.co.uk

Or by post to:

Access & Education, Phoenix Dance Theatre, St Cecilia Street, Quarry Hill, Leeds, LS2 7PA

If you need any advice or support in completing this form or have any questions about NO BOUNDS then please do not hesitate to contact a member of the Access & Education team on 0113 236 8130.

Thank you!