Student first name

Student surname

School

Date of birth

Gender

School Year School YearYear 4Year 5Year 6

What support could this group offer: What support could this group offer: Social Interaction Co-operation Language Development Communication Emotional resilience Confidence Musical and social skills Independent learning Sense of community

Parent / Carer Title (e.g. Mr, Mrs, Ms etc)

Parent / Carer First Name

Parent / Carer Surname

Address (Number and Street)

Address (Area/Estate)

Address (Town/City)

Post Code

Phone number

E-mail address

Emergency contact information

Any relevant medical information

Does your child have any special needs 'SEND'? Does your child have any special needs 'SEND'? Yes No

Declaration Declaration On behalf of the student named above, I apply to MK Music Service for membership of the specified activities.

Terms and conditions Terms and conditions I have read the terms and conditions relating to ensembles and classes and agree to abide by them. Terms and conditions

Photographic Consent - Photography, Film and Audio: Milton Keynes Music Service is part of MK Council and occasionally uses photography for publicity purposes. We would like your permission to photograph/film/record audio of your child for possible inclusion in promotional material, website and other publicity material including social media. We will ensure as far as possible that the images/video/audio are not used inappropriately but by submitting this permission form you accept that should this happen, the council does not accept responsibility. Your contact details will remain strictly confidential. Photographic Consent - Photography, Film and Audio: Milton Keynes Music Service is part of MK Council and occasionally uses photography for publicity purposes. We would like your permission to photograph/film/record audio of your child for possible inclusion in promotional material, website and other publicity material including social media. We will ensure as far as possible that the images/video/audio are not used inappropriately but by submitting this permission form you accept that should this happen, the council does not accept responsibility. Your contact details will remain strictly confidential. I give photographic consent I do not give photographic consent