Parent/Carer Details

Title Mr Mrs Miss Ms Dr Prof Other

Other title

If title is 'other' then please enter title here.

First name *

Surname *

Address 1 *

Address 2

Town *

County * West Sussex Aberdeenshire Anglesey Angus Antrim Argyllshire Armagh Ayrshire Banffshire Bedfordshire Berkshire Berwickshire Brecknockshire Bristol Buckinghamshire Buteshire Caernarfonshire Caithness Cambridgeshire Cardiganshire Carmarthenshire Cheshire City of London Clackmannanshire Cornwall Cromartyshire Cumbria Denbighshire Derbyshire Devon Dorset Down Dumfriesshire Dunbartonshire Durham East Lothian East Riding of Yorkshire East Sussex Essex Fermanagh Fife Flintshire Glamorgan Gloucestershire Greater London Greater Manchester Hampshire Herefordshire Hertfordshire Inverness-shire Isle of Wight Kent Kincardineshire Kinross Kirkcudbrightshire Lanarkshire Lancashire Leicestershire Lincolnshire Londonderry Merioneth Merseyside Midlothian Monmouthshire Montgomeryshire Morayshire Nairnshire Norfolk North Yorkshire Northamptonshire Northumberland Nottinghamshire Orkney Oxfordshire Peeblesshire Pembrokeshire Perthshire Radnorshire Renfrewshire Ross-shire Roxburghshire Rutland Selkirkshire Shetland Shropshire Somerset South Yorkshire Staffordshire Stirlingshire Suffolk Surrey Sutherland Tyne and Wear Tyrone Warwickshire West Lothian West Midlands West Yorkshire Wigtownshire Wiltshire Worcestershire

Postcode *

Email address *

A copy of your form submission will be sent to this email address.

Preferred phone number *

Other phone number

Student Details

First name *

Surname *

Gender * Male Female

Date of birth *

DD/MM/YYYY.

School from September 2020 *

Year Group from September 2020 * 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

Town of school from September 2020 *

School - Town *

Special Educational Needs/Disabilities

Special Diet

Any Medical Conditions

If yes it is important to fully disclose all information

Musical Details

Instrument / Voice / Theory * Baritone Bass Guitar Bassoon Cello Clarinet Cor Anglais Cornet Double Bass Drum Kit Euphonium Fife Flute French Horn Guitar Harp Keyboard Oboe Percussion Piano (individual lessons only and not available to hire) Piccolo Recorder Saxophone Tenor Horn Trombone Trumpet Tuba Theory Ukulele Viola Violin Voice

Current standard * Beginner Foundation Stage Preparatory Stage Stage/Grade 1 Stage/Grade 2 Stage/Grade 3 Stage/Grade 4 Stage/Grade 5 Stage/Grade 6 Stage/Grade 7 Stage/Grade 8 Diploma

Length of time learning * 0 months 6 months to 1 year 1 to 2 years 2 to 3 years 3 to 5 years More than 5 years

If currently learning, full name of instrumental/vocal teacher

Have you previously completed an application for the Instrument / Voice above? * Yes No

If yes, please select reason for your new application Lessons were not previously available ‘Removal from Waiting List’ email received Cancelled lessons, and now wanting to re-start

Bursary Fund - check to see if your child is eligible for our West Sussex Music Trust Bursary Fund

Does the student receive benefits related free school meals? * Yes No

Is the student currently in care? * Yes No

Are you in receipt of income support or other benefit? * Yes No

If yes, please detail:

Where did you hear about West Sussex Music? Search engine School or college Advert Recommendation

If you heard about West Sussex Music from a different source then please enter it in the 'Other source' field.

Other source

Regulations and Conditions

We want you to know exactly how our service works and why we need yours and your child’s details. Please state that you have read and agreed to these terms before you continue. * I agree to the Regulations and Conditions

Consent for online learning * I confirm that I have read and agree to the conditions outlined in the guidance document, and consent to my child learning online I do not wish for my child to learn online

Data Protection

Please tick to confirm that you have read our Data Protection Policy (GDPR 2018) * I agree to the Data Protection policy.

Privacy Notice

This notice explains why we collect personal information about our customers and how we use it. Please confirm that you have read our privacy notice and understand how we will use your personal information. * I have read the Privacy Notice.

Photo Permission

Occasionally we would like to record or photograph lessons and performances and will sometimes use these images on our website and in publicity material. At no time will the name of any child be made public. Please indicate your consent for us to use images of your child by selecting one of the following options: * Yes, I consent to the use of images of my child No, I do not consent to the use of images of my child

Contact Permission

From time to time, we would like to send you details of relevant musical opportunities for example concerts, excursions, and events or ways to support us which may be of interest to you. * Yes please, I'd like to hear about these opportunities. No thanks, I don't want to hear about these opportunities.

Declaration

You must be over 18 to apply for our services and you must have legal responsibility for the child named in this application. * I confirm that I am the parent/carer of the child named in this application and that I am over 18 years of age.

ELECTRONIC SIGNATURE BOX OF APPLICANT *

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