To apply for a music centre membership please complete the form below. Name of Child *School *Music Group Applied for *Name of Parent/Carer *FirstLastInstrument *Date of Birth of the Child *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender of the child *FemaleMaleEthnicityBangladeshiIndianBlack AfricanPakistaniBlack CaribbeanOther AsianBlack OtherWhiteChineseOtherAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeHome TelephoneMobile/Emergency Tel *Email * Free School Meals then you can apply for free ensemble membership. *My child receives Free School MealsMy child DOES NOT receive Free School MealsYour child’s school will be contacted to confirm the Free School Meal status and once confirmed the free membership would last for the remainder of that academic year. This would then be reviewed in September each year. LAC *YesNoDoes your child have any relevant medical conditions or additional need *If 'YES' please specify.I will complete and return a direct debit form *YesNoBilling address if different from the child's addressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeI understand that by signing this contract I will be liable for any applicable termly payments until written or email confirmation is provided of withdrawal. I accept the terms and conditions. *YesNoNon-payment of any kind which results in lesson/membership being cancelled will incur a £10 admin charge for reinstatement. Any lessons/membership dates missed due to cancellation by the Service in relation to failure to pay within stated times scales will not be made up if lessons/membership are reinstated Please Indicate how you heard about the Music Centre *Music TeachSchoolFlyerOnlineOtherPlease State OtherNB All communication from Music & Arts Service will be via email or text so please ensure this information is accurate.The Bradford Music & Arts Service would like to be able to take photographs/video footage/audio of your child to use within the remit of Service activities. The Music & Arts Service operates under Bradford Council. Images/video footage may be used by the Music & Arts Service and Bradford Council to share performances/work undertaken by your child, for publicity and advertising materials, including printed publications, and presentation and exhibition materials. We will use websites, social media, email and other digital communications, including online advertising. They may also be used for news media and their associated websites and social media channels including printed newspapers, magazines, television and radio. Your images/video footage and details will not be sold to a third party and will be stored up to a maximum of 5 years. This form also covers any video recordings your child makes of their playing as part of Music Centre activity. Please confirm that the Bradford Music & Arts Service has your consent by electronically signing this form. Media Consent for Music Centre MembersI give my permission for Bradford Music & Arts Service and Bradford Council to use the photography or video taken for Publicity and advertising materials, including printed publications. * *YesNoI give my permission for Bradford Music & Arts Service and Bradford Council to use the photography or video taken for presentation and exhibition materials. * *YesNoI give my permission for Bradford Music & Arts Service and Bradford Council to use the photography or video taken for news media and their associated websites and social media channels including printed newspapers, magazines, television and radio. * *YesNoI give my permission for Bradford Music & Arts Service and Bradford Council to use the photography or video taken for news media and their associated websites and social media channels including printed newspapers, magazines, television and radio. * (copy) *YesNoName of person giving consent * * I understand that the image/s or video footage will be stored electronically in accordance with Data Protection laws and may be used for up to 5 years from the date of signing. I have the right to withdraw this consent at any time by writing to Bradford Music & Arts Service, 21 Market Street, Shipley, BD18 3QD or by emailing schoolsmusicandarts@bradford.gov.ukRelationship to the child of the person giving consent. * Electronic signature *NameSubmit music-centre-groups-terms-conditions
