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Free membership form

HEAD2HEAD THEATRE FREE MEMBERSHIP FORM

SHORT BREAKS PROVISION:   FAMILY ACTIVITY DAYS

By completing this form I confirm that I am happy for Head2Head to keep the below data solely for the purpose of contacting me regarding its events and support.  I understand that Head2Head will not share my data with any third party and will store it responsibly.

Full name of child

 

Child’s ethnicity:

 

Child’s date of birth

 

Male:

 

Female

 

Brief details of  child’s disability

 

 

Mobility issues

 

 

School

 

 

Name of parent/carer

 

Relationship to participant:

 

Parent/carer’s contact details

Mobile: 

 

Landline: 

 

 

Email:   

 

 

Emergency contact details

Name: 

 

Mobile:   

 

Sibling

First name: 

 

Year of birth:

 

Sibling

First name: 

 

Year of birth:

 

Sibling

First name: 

 

Year of birth:

 

Sibling

First name: 

 

Year of birth:

 

Where do you live?

 

Town: 

 

Postcode:

 

How did you hear

about us?

 

 

I am happy for the participant & any siblings to be photographed for Head2Head publicity.

YES

 

NO

 

I confirm that the participant has (or is applying for) an EHCP or has a life limiting limiting / threatening condition

YES

 

NO

 

IMPORTANT INFORMATION

v Tell us as soon as possible if you cannot attend

v We have £10m public liability insurance, safeguarding policy and risk assessment – please ask for copies

v You will receive an advance pack and full details of any event booked date but if you have any queries please contact us – we are happy to chat through any concerns you may have

v Please note that, while every effort has been made to ensure the safety of the children, it is the parent/carers’ responsibility to ensure that children are safe & accompanied at all times

v All venues have accessible toilets, some have hoists & changing facilities – please ask

BACS PAYMENTS

CAF Bank A/C No:  00027692 (Head2Head Theatre)

Sort Code

40-52-40

Reference:

[participant’s name & date of performance

CHEQUE PAYMENTS

Cheques (payable to Head2Head Theatre) should be sent to:

Head2Head Theatre, 15 Ralliwood Road, Ashtead, Surrey KT21 1DD














Head2Head Theatre, 15 Ralliwood Road, Ashtead, Surrey KT21 1DD

Tel/Fax:  01372 278021      07519 747 290     office@head2headtheatre.co.uk

http://www.head2headtheatre.co.uk/family-holiday-activities

PLEASE NOTE:  All correspondence should be sent to the above address (fax, email or post)

Registered Charity No. 1161873