Membership | Gonzo Youth Theatre | Cavan | Facilitator Kevin O'Connor

Section A: Member Details (Sibling #1)

Name *

First

Last

Date of Birth

Mobile

Member Details (Sibling #2)

Fill this section in if you have a second child attending. Go straight to Section B if you don't.

Name

First

Last

Date of Birth

Mobile

Member Details (Sibling #3)

Fill this section in if you have a third child attending. Go straight to Section B if you don't.

Name

First

Last

Date of Birth

Mobile

Section B: 1st Parent / Guardian Details

Name *

First

Last

Email *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Phone

Mobile

2nd Parent / Guardian Details

Name *

First

Last

Email *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Phone

Mobile

Checkboxes *

I (Parent/Guardian) consent to be contacted for the purpose of verifying my identity as parent/guardian of my child. (Please tick)

Medical Conditions/Additional Requirements

If you do not have sufficient space to provide full details, please complete the attached Additional Information Sheet. Any information provided will be treated as confidential and managed in line with the youth theatre’s Confidentiality Policy.

1. Does your son/daughter/ward have any additional requirements? (e.g. physical disability, learning difficulties or literacy issues)

If ‘Yes’, please give details:

Details

2. Does your son/daughter/ward have any medical conditions of which we should be aware?

If ‘Yes’, please give details:

Details

3. Does your son/daughter/ward have any allergies?

If ‘Yes’, please give details:

Details

4. Is there any other information we need to be aware of that may impact on your son’s/daughter’s participation in youth theatre?

If ‘Yes’, please give details:

Details

Membership Application Form

Please fill out each section of the below Application Form. Payment with your Credit or Debit Card can be made at the end.

Section A: Member Details (Sibling #1)

Member Details (Sibling #2)

Member Details (Sibling #3)

Section B: 1st Parent / Guardian Details

2nd Parent / Guardian Details

Medical Conditions/Additional Requirements

Section C: Parental Consent

Section D: Members’ Consent For Photos

Section E: Members’ Consent For Personal Data

Section F: Gonzo Youth Theatre Membership Payment

Are you interested in joining Gonzo Youth Theatre?