8/11/2019 Annual Membership Form- Youth Arts Jersey
2014/2015
1/2
2014/2015
Youth Arts JerseyAnnual Membership Form
PLEASE FLL !"# $ %L!&' &AP#ALS
Y!"#( MEM%E)S(P* F)EE
1+ Membership $umber:
__________________________________ (if you had one before please
complete)
2+ Personal ,etails
Your first name: ____________________________Your last
name:___________________________
Home address: ________________________________________
________________________________________
_______________________________________________________________
____________________________________________________
Parish: ______ Post code: ______
Home telephone number: _________________ Your mobile number:
________________________
Personal email:
____________________________________________________________________
Gender (circle one): Male Female Date of birth:
______/________/_________
-+ %a.roun * hich one of these best describes your bac!"round
(circle one) :
hite #ersey hite $ritish hite %uropean hite other
$lac! &aribbean $lac! 'frican $lac! other 'sian
ther
4+ S.hool/&ollee inormation * f you are at school or
colle"e:
*ame of school/colle"e:
_____________________________________________________________
Year "roup: _________________ +chool/colle"e email:
____________________________________
3P#!
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8/11/2019 Annual Membership Form- Youth Arts Jersey
2014/2015
2/2
5+ Emeren.y .onta.t * hich adults can ,e contact if there is an
emer"ency(&ircle relationship to you for each)
&onta.t 1
Mother/father brother/sister "randparent "uardian partner
-heir *ame:
__________________________________________________________________
-heir *umber:
_________________________________________________________________
&onta.t 2
Mother/father brother/sister "randparent "uardian partner
-heir *ame:
__________________________________________________________________
-heir *umber:
_________________________________________________________________
+ &onitions /Support nees * hat medical conditions.
aller"ies or special support needs should,e be a,are of
66666666666666666666666666666666666666666666666666666666666666666666666
7+ Areement
ha8e rea an aree to the rules o membership belo9 :
0) Members are e1pected to sho, appropriate care and
consideration for:2i) The Project Equipment & Premisesii)
Fellow Users and Membersiii) Staff and Helpers3) *o into1icatin"
substances. le"al or other,ise. should be consumed or brou"ht onto
Pro4ect /&entrepremises5 6sers/Members ,ho are under the
influence of such substances may be e1cluded frompremises or
participation in e7ents/acti7ities58) 'll 6sers and Members ha7e a
responsibility to ensure premises are ,elcomin" and safe59)
+pecific rules re"ardin" smo!in" should be obser7ed for the comfort
of e7eryone5) 'busi7e. discriminatory and/or a""ressi7e beha7iour
,ill not be tolerated5;) +taff are not responsible for the care of
Members ,ho lea7e the immediate premises or ,ho are noten"a"ed in
an or"anised acti7ity5
e.lare that the inormation on this orm is .orre.t+ ully unerstan
the e.larations abo8e ana..ept that it is my responsibility to
inorm the pro;e.t o any .hanes to etails .ontaine on this
ormin.luin any .hanes in mei.al .onitions or isability status+
+i"nature of 'pplicant _________________________________ Date:
___/____/____
,ata Prote.tion 3Jersey La9 2005 ,e.laration:-he information
collected from you on this form. and any fin"er scan or ,ebcam
ima"e. ,ill only be used for the purposes ofadministration and
monitorin" of your Youth +er7ice membership and ,ill not
bedisclosed to anyone else unless re
