2014/2015

YOUTH ARTS JERSEY

Annual Membership Form

PLEASE FILL OUT IN BLOCK CAPITALS

ASSOCIATE MEMBERSHIP (Sept 2014 - Aug 2015: 15)

1. Membership Number:

__________________________________ (if you had one before please complete)

2. Personal Details
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 : ______/________/_________

3. Background - Which one of these best describes your background (circle one) :
White Jersey

White British

White European

White other

Black Caribbean

Black African

Black other

Asian

Other
4. School/College information - If you are at school or college :
Name of school/college: _____________________________________________________________
Year group: _________________School/college email :____________________________________

(please turn over

5. Emergency contact - Which adults can we contact if there is an emergency

(circle relationship to you for each)
Contact 1
Mother/father

brother/sister

grandparent

guardian

partner

Their Name : __________________________________________________________________

Their Number : _________________________________________________________________
Contact 2
Mother/father

brother/sister

grandparent

guardian

partner

Their Name : __________________________________________________________________

Their Number : _________________________________________________________________
6. Conditions /Support needs - What medical conditions, allergies or special support needs should
we be aware of ?
_______________________________________________________________________

7. Agreement
I have read and agree to the rules of membership below :
1) Members are expected to show appropriate care and consideration for:i) The Project Equipment & Premises
ii) Fellow Users and Members
iii) Staff and Helpers
2) No intoxicating substances, legal or otherwise, should be consumed or brought onto Project /Centre
premises. Users/Members who are under the influence of such substances may be excluded from
premises or participation in events/activities.
3) All Users and Members have a responsibility to ensure premises are welcoming and safe.
4) Specific rules regarding smoking should be observed for the comfort of everyone.
5) Abusive, discriminatory and/or aggressive behaviour will not be tolerated.
6) Staff are not responsible for the care of Members who leave the immediate premises or who are not
engaged in an organised activity.
I declare that the information on this form is correct. I fully understand the declarations above and
accept that it is my responsibility to inform the project of any changes to details contained on this form
including any changes in medical conditions or disability status.

Signature of Applicant _________________________________

Date: ___/____/____

Data Protection (Jersey) Law 2005 declaration :

The information collected from you on this form, and any finger scan or webcam image, will only be used for the purposes of
administration and monitoring of your Youth Service membership and will not be disclosed to anyone else unless required by
law, it is a medical emergency or by getting your agreement beforehand.
La Motte Street Studios use bulk mailing to update members with project information Your signature above agrees to this
practice using your given email address

Sept 2014