Dance WokingPearl Assurance House, 28 High Street, Woking, GU21 6BW

01483 495460 | www.dancewoking.comRegistered in England 2963208 | Registered Charity No. 1042690

Dear Parkour participant and Parent,

Dance Woking Rotate Parkour

Dance Woking has set up a NEW weekly Parkour session called Rotate in partnership Active Surrey and Runnymede Families Team led by Momentum free runners.

Suitable for 11 years+

Rotate – Parkour – Mixed groupThursday evenings: 6pm – 7pm Term Dates 2019: 24th January – 4th April (No class 21st February)Venue: Addlestone Youth Centre, 121-125 Church Rd, Addlestone KT15 1SH

If you would like to attend please complete the booking form and return to Gemma Rutter, at the Youth Centre or Dance Woking, Pearl Assurance House, 28 High Street, Woking, GU21 6ET or office@dancewoking.com FAO Kate Finegan.

We really hope you can be involved in these exciting new dance clubs; we look forward to either dancing or delivering

parkour with you!

Best wishes,The Dance Woking Team

T: 01483 495 460E: office@dancewoking.com

Dance Woking is supported by:

Q1. What is your name?Surname: Forename:Q2. What is your email address?

Q3. If any what school/college do you attend?

Q4. What is your mobile number?Q5. What is your gender? Male Female Prefer not to sayQ6. What is your postcode?Q7. How old are you?Q8. Which ethnic group do you consider yourself to belong to? (Please tick ONE below)

White Mixed/ Multiple Ethnic Groups

Asian/Asian British

Black/Black British

Other Prefer not to say:

Q9. Do you consider yourself to have a disability? (please tick ONE below)Yes No Prefer not to sayQ10. In the past 4 weeks, on how many days have you done 30 minutes of sport and/or recreational physical activity? (Do not count any curriculum activities at school/college. Do not include cycling or walking unless it was for sport or recreation. Gardening, DIY and housework should not be included.) Please write in the number of days between 0-28:

Emergency Contact DetailsName: Relationship to you:Phone number?Relevant Medical Information:(include any allergies/injury problems)I have completed the medical details above and I consent that, in the event of any illness/accident, any necessary treatment can be administered, which may include the use of anaesthetics.Signature (parent/carer if under 16):Date:

Given the nature of the project, it is likely that participants will have some physical contact with fellow participants (other children). Any concerns please contact Dance Woking or Gemma Rutter

The information you have given will be used to monitor the success of the programme and help us plan for future sporting activities. Sport England would like your permission to share your contact details as follows:

Consultants working for Sport England to monitor Satellite Clubs may want to send you a survey. Please tick here if you DO NOT want to be sent the survey by email:

Please tick here if you DO NOT want to be sent the survey link by text to your mobile:

Dance Woking may wish to notify you about other activities. Please tick here if you DO NOT want to be notified:

We will collect and process all personal data in line with the Data Protection Act 1998 and there is more information about this on the Data Protection Statement supplied with this form. Dance Woking will not share your data PHOTOGRAPHY/FILMING - There may be filming and photography at some sessions which may be used in publicity materials e.g. leaflets, newsletters or on official websites. Dance Woking will ensure that images are not accompanied by names or details that could identify individuals.

I DO / DO NOT give permission to be filmed or photographed during Satellite Club activities as described above (Please delete as appropriate).