Sign Up Form | Icon Theatre

Email address *

Name of Parent, Carer or Guardian *

First Name of Young Person *

Last Name of Young Person *

Gender *

Female Male Transgender Gender Non-Conforming Prefer not to say Other

Street Address *

Address line 1

Address line 2

Postal Code *

Birth Date *

School Attended *

Home Number *

Mobile Number *

Emergency Contact Name *

Emergency Contact Number *

Please state any information about your child that you think would be useful for us to know (health, behaviour, medication) *

Please state any activities or hobbies currently of interest to your child: *

Icon Theatre collects this information for funding and monitoring purposes. How would you describe the ethnic origin of your child?

Ethnic Origin Information *

Ethnic Origin Other

Sexual Orientation *

Straight Bi-Sexual Lesbian Gay Queer Something Else Do not wish to answer Not Known

I consent to the following statement: *

Yes

I consent to the following statement:
1. I understand the organisers of the activities will take all reasonable precautions for the care and safety of those taking part and their property. I understand that the organisers are only responsible for any injury and/or for the loss of personal property should this be caused by their negligence.
2. I understand should I /my child /my young person require medical or surgical treatment, the organisers will make every effort to contact the appointed ‘emergency contact’ before treatment is given. If however; this is not possible I agree that the organisers may consent to emergency medical treatment.
3. I agree to reimburse the organisers for any necessary expenditure, which maybe incurred in the case of emergency.
4. I understand that for the safety of the group, I /my child /my young person will adhere to the instructions of the members of staff running the session.

Photographs and filming permissions *

Photograph and video Live streaming and broadcast No

Photographs and filming permissions
Please note that Icon Theatre and /or Theatre31 may want to document activities in the form of photograph and /or video. Images and footage may be used to create marketing and press materials to promote both Icon Theatre and Theatre31 plus our partners.
Please tick to give consent to the above statement for yourself /your child /your young person: