Name: Chelsea Youth Club Summer Programme - Liquid Leisure
Start: 2022-8-3
End: 2022-8-3

Applicant details
Which club would you like to attend?*
Name of Young Person*
First Last
Address*
Street Address City Postcode
Email*
Enter Email Confirm Email
Mobile Phone*
Home Phone
Education Centre
Date of Birth*
DD slash MM slash YYYY

Emergency Contact
Emergency Contact*
First Last
Relationship*
Please specify*
Emergency Contact Phone Number*
Emergency Contact Email Address
Enter Email Confirm Email

Consent
Data Consent:*
Please tick to indicate you agree to us holding this data.
Harrow Club W10 uses the above data to be able to communicate with you, to ensure we are aware of any medical conditions or disabilities and to provide data to our funders. For more information on our privacy policy, please see our website – harrowclub.org
Photographic/Video Consent:*
Please tick below to indicate if you are willing for your child’s image to be used for these purposes.
From time to time, we may take photographs and/or videos of our activities and those who
participate in them in order to evidence activities and also for youth club promotional purposes.
We may wish to upload content to our website and social media platforms such as Twitter,
Facebook and Instagram. Photographs and videos will be stored on the Harrow Club network, in the Management Section which is only accessible to the Senior Management Team. Photographs will be stored for a maximum of 5 years.

Please note that, if, having given consent, you subsequently withdraw it, it may not always be possible to delete images that have already been shared or published.
Is the applicant under 18 years of age?*
- Yes
- No
Signature*
To be signed by the parent/carer if the member is under 18 years old
Pledge*
I agree to the terms listed in the membership above, and state that all the information listed is correct, to the best of my knowledge.
As a Club, we PLEDGE to provide a safe, well-equipped and welcoming club that offers positive opportunities to our members, where they can meet friends free from violence and aggression.

In return, members must agree to behave in a manner that respects other club users, the club itself and its equipment, while following our code of conduct. Members must also agree that they will not attend whilst under the influence of alcohol or any illegal substances.
Signature*
To be signed by the member if over 13 years’ old or by the parent/carer if under 13 years’ old
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Time

Data Protection

Step 1 of 4 - Applicant details

Applicant details

About you

Emergency Contact

Consent