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Please use this form to register your place in our In Harmony Lambeth after-school clubs Contact Details Childs First Name Childs Surname Gender PLEASE SELECT MALE FEMALE Childs Date of Birth Please input dd/mm/yyyy School Year PLEASE SELECT Pre-school Reception Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Year 11 Year 12 Year 13 School Parent/Carer Title PLEASE SELECT Mr Mrs Ms Miss Dr Other Parents First Name Parents Surname Telephone Please include area code Mobile Emergency Contact No. Email Address Line 1 Address Line 2 Address Line 3 Address Line 4 Postcode eg SE11 5LG Please tick the courses you are currently attending from the table below: Day Location Time Event Click Monday St Stephens 3.30-4.30 Recorders Monday St Stephens 3.30-4.45 Wind Monday Lansdowne Green 4.00-5.30 String class Tuesday Herbert Morrison 3.30-5.00 Wind/Perc Tuesday Herbert Morrison 3.30-5.00 Yr 2 strings Wednesday Lansdowne Green 4.00-6.00 Strings Wednesday Lansdowne Green 5.30-7.30 Music tech Thursday St Stephens 3.30-4.30 Yr 2 Strings Thursday Herbert Morrison 3.30-5.00 Yr 3 Strings Friday St Stephens 3.30-5.00 Yr 3 Strings   What instruments do you play? 1) 2) Do you have internet access? PLEASE SELECT YES NO Do you have an In Harmony laptop? PLEASE SELECT YES NO Additional Details Does your child have any medical conditions/or allergies we need to be aware of? In the unlikely event of your child being unwell or injured, are you happy for us to arrange medical help? PLEASE SELECT YES NO Does your child have Special Educational Needs? (please give details) Any other details we should know? Going home details (who will be taking your child to/from the centre, please give as much info as needed) Ethnic Origin PLEASE SELECT White - British White - European White - Irish Black/Black British - African Black/Black British - Caribbean Black/Black British - Other* Asian/Asian British - Pakistani Asian/Asian British - Indian Asian/Asian British - Bangladeshi Asian/Asian British - Other* Mixed - White & Black African Mixed - White & Black Caribbean Mixed - White & Asian Mixed - Other* Chinese Other* Prefer not to state *if other ethnic origin, please state: Does your child receive Free School Meals? PLEASE SELECT YES NO Please read the following: Due to the nature of the In Harmony Lambeth project, it is inevitable that students will be filmed/photographed on occasion and we require parents/carers consent for this. For more information please read our publicity permission information slip I have read and agree with the Publicity Permission Slip and give permission for my child to be filmed/photographed as part of the In Harmony Lambeth project PLEASE SELECT YES NO Click here to read th In Harmony Lambeth clubs Behaviour Policy I have read and agree to the clubs Behaviour Policy Thank you for completing this form, click submit to complete your registration

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Last Updated : 23 February 2012