RADCLIFFE-ON-TRENT COMMUNITY YOUTH PROJECT
DROP-IN MEMBERSHIP FORM
Radcliffe-on-Trent Community Youth Project
www.rotcyp.org
Chair: Rosie Luce
A Company Registered in England & Wales: 7108896
Registered Charity Number: 1135489
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Radcliffe-on-Trent Community Youth Project: Drop –In Membership Form
Radcliffe-on-Trent Community Project – drop in is an open access provision. Open access
provision is where children/young people may come and go freely; that is where there is no
requirement for children to be either brought to or collected from the provision by an adult.
Date of first contact with young person:
Young person's name
Young person's email
Young person's mobile number
Date of birth
Gender
(please tick)
/
/
Age
Male
Female
Ethnicity Information
White
Dual Background
Asian or Asian British
British
White & Black
Caribbean
Indian
Irish
White & Black
African
Pakistani
Other (specify)
White & Asian
Bangladeshi
Other (specify)
Other (specify)
Black or Black
British
Caribbean
Chinese or other
ethnic group
Chinese
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African
Chinese other
Other (specify)
Other (specify)
Disability Information
Would you consider yourself as having any disabilities?
YES
NO
If YES, how would you describe these? (please tick all that apply)
Learning difficulty
Visual impairment
Physical impairment
Other/hidden impairment
Hearing impairment
If other, please describe here:
Is there anything specific we can do to help you enjoy the full range of
activities?
Emergency Contact Details
Name
Contact number
Relationship to young person
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Young person's address
Postcode
Home contact number
Data Protection Act
The paper copy of this form will be kept in a secure and locked place at the Methodist
Church Hall site so that we know who to contact in an emergency and so we know who we
are giving a service to.
The information on this form will also be scanned and kept in an encrypted electronic data
folder and held by Rosie Luce, Chair of ROTCYP. Your personal details will also be put into
the encrypted electronic data folder.
The access to the information on this encrypted data folder is strictly limited to Chair,
trustees and staff related to activities of the Radcliffe-on-Trent Youth Project.
Information regarding ethnicity and disability will be recorded so we can ensure we provide
a service for people from many different backgrounds. However, we will not give away any
personal information about you with anyone outside of the Youth Project without asking
you first.
We would like to occasionally send you information about Radcliffe-on-Trent Youth Project
activities that may interest you.
By ticking the following boxes you agree to ROTCYP contacting you in the following ways:
Correspondence by post
Text Messages
Email
Image consent
Radcliffe on Trent Youth Project would like to take your photo/video for membership cards,
promotion and publicity for Radcliffe on Trent Youth Project, which links to the Radcliffe on
Trent supporting churches. This applies to all forms of media whether digital, electronic or
print. The purpose behind publication is to promote and encourage new members and
volunteers and to attract or retain funders to support community and Youth activities.
Please note, although this may be rare, you must tell us if you know that there is a court or
other legal document that stops us from publishing your image.
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By ticking the following boxes you are confirming there are no legal documents that stop us
from using your image, and that you agree to Radcliffe on Trent Youth Project using your
photo for:
Membership Cards
Promotion & Publicity
No legal orders prohibiting
publication on your image
Young person
(name) representative
Signature _______________________
Signature ___________________________
Date of registration _______________
Date of registration ___________________
Parent/Carer signature
(if under 16 years) _____________________
Date of signature _____________________
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