<p> Hackney Village at Hackney Empire 2017 21st August – 25th August</p><p>REGISTRATION FORM Please make sure that you fill out this form with as much detail as possible. </p><p>Date: ______</p><p>Name of Child: ______Age: ___ Date of Birth: ______Gender of Child: Male / Female (please circle as appropriate) Name of Parents / Guardians ………………………………………………………………. Address…………………………………………………………………………… .…………...………………... ………………………………………………………... ……………………………………………………………………………………. ……………………………………………………………………………………… Parents Phone No. Home………………… Mobile …….…………… Work….………… Please give us a number we can contact in the event of an emergency. Name, address & number of Social Worker (if you have one) ……………………………………………………………………………………… .……………………………………………………………………………………... ______</p><p>School/college Name & Contact ……………...…………………………………………... Doctor Name and Address……………………...…………………………………</p><p>Outline disability (e.g. mild learning disability, hearing impaired, wheel chair user etc.) We need as much detail as possible. It is important that you mention any behaviour that may be challenging and that we will need to be aware of in order to give your child the best experience of this event. ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… ……………………………………………………………………………………… If you need a one to one support worker, please confirm that you will be bringing that one to one support worker with you. Name of Support Worker: Telephone number of Support Worker: Medical details (please list any medical details we would need to know to work with the young person including any viral infection, medications, or dietary needs/allergies etc.) ……………………………………………………………………………….. ……………………………………………………………………………….. ……………………………………………………………………………….. ……………………………………………………………………………….. ______</p><p>Any other information you think we should know (e.g. religious observances) ……………………………………………………………………………….. ………………………………………………………………………………..</p><p>What other clubs / out of school activities do you/your child attend at present? (Please specify) ……………………………………………………………………………….. ……………………………………………………………………………….. ……………………………………………………………………………….. Photo Consent: I consent to photos being taken of the attendee for the purposes of reporting on the success of the event: YES/NO</p><p>I verify that the information given is accurate Parent/Guardian signature………………………………. Date………………….</p><p>IMPORTANT: There will be a limited amount of spaces. Filling out this form does not guarantee you a space. It does put you on a waiting list. We will contact you in advance if you have been successful. (please make sure all your contact details are accurate)</p><p>This is a week full of group activities. There will be drama, music and art and a final performance at the end of the week. Please make sure that your child wears appropriate clothing all week that they don’t care too much about. There will be painting so old clothes are preferable. We cannot be held responsible for damage or paint to clothes.</p><p>For official use at visit Date……... Staff member……………………………………… Please return completed forms to: [email protected] or post to Anjie/ Cassandra: The Huddleston Centre, 30 Powell Road, Clapton Pond, E5 8DJ</p>