Student Form
Please use one form for each person.
Child’s Name ; _________________________
Age: ___________ Date of Birth: ___________________________
Guardian’s Name : ______________________ Contact Phone Number: ___________________
Email Address: ___________________________________
Contact name of another Adult ( In case of emergency ) : ___________________________
Phone Number : __________________________ Email address :__________________________
In the case of an emergency and I cannot contact you or the second adult listed, for some reason, do I have permission to bring your child to a doctor or hospital ? __________________________
Please note all answers are in strictest confidence.
Please list here any relevant medical information which would enable me to better help me attend to your child’s needs ( epilepsy, asthma, Learning or mobility needs, allergies ) Please note I strongly advocate an inclusive policy where every student deserves access to fun social engagement.
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Does your child have any anxiety, grief, identity or confidence issues ? Frequently we can build in uplifting and supportive elements to the Workshops
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From time to time, during workshops, Field Trips and Exhibitions we may photograph students creating. Please circle your choice below
I do/ do not consent to my child ( full name ) _______________________ being photographed for use on Mary Murphy’s Website /social media, (no child named) .
Signed: Guardian _____________________
Please print this and place it in the fees envelope, marked with all contact details, to be handed up on the first day of term.
Looking forward to creating with you !
Mary
Nat. Deg in Des. H Dip in Ed. LSDI