LEVEL BLEND Register of Interest

Level BLEND

Please complete this form to register your interest in Level BLEND. If you have any queries, please contact projects@levelcentre.com for more information.

Young Person's Details

Name *

Date of Birth *

Street Name *

House name/number *

City *

Postal Code *

Country *

Does the young person have any medical conditions, allergies or disabilities we should know about? Or are there any activities that the young person cannot participate in? *YesNo

If you answered ‘yes’, please use this space to provide details, including how we can help.

What is your young person interested in? For example art / drama / dance / work experience etc. *

What would they like to achieve by taking part? *

Parent/Guardian Contact Details

Please complete

Name *

Parent/Guardian phone number *

Email address of parent/guardian *

Emergency Contact Details

Please complete if different to parent/guardian's contact's details

Emergency contact name *

Emergency contact phone number *

Relationship of emergency contact to young person *

Who will be bringing the young person to LEVEL on a regular basis? *

Photo and Video Consent

We may occasionally take photographs and videos of LEVEL Centre activities which we may use for promotional purposes such as social media, website and brochures. Please tick ‘yes’ if you are happy to give your consent for this.

Please tick ‘yes’ if you are happy to give your consent for this. *YesNoNote: if consent is not given, LEVEL Centre will not use any images of the young person taken during the activity

GDPR

To be completed by the parent/guardian

GDPR *Yes, I agree with the privacy policy and terms and conditions.