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2012/2013Jersey Youth Service

Annual Membership FormSTUDIOS

PLEASE FILL OUT IN BLOCK CAPITALS

IF YOU ARE IN YEAR 7 & OVER PLEASE COMPLETE YOURSELFIF YOU ARE IN YEAR 6 AND UNDER THIS MUST BE COMPLETED

BY AN ADULT RESPONSIBLE FOR CARING FOR YOU

1. Membership Number :

__________________________________ (if you had one before please complete)

2. Personal Details

Your first name: ____________________________Your lastname:___________________________

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 :

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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 shouldwe 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 & Premisesii) Fellow Users and Membersiii) Staff and Helpers2) 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 excludedfrom 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 arenot engaged in an organised activity.

I declare that the information on this form is correct. I fully understand the declarations above andaccept that it is my responsibility to inform the project of any changes to details contained on this formincluding any changes in medical conditions or disability status.

Young person (if in year 7 and over) _________________________________ Date: ___/____/____

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