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2013/2014 Jersey Youth Service

Annual Membership Form



1. Membership Number:

__________________________________ (if you had one before please complete)

2. Personal Details Your first name: ____________________________Your last name:___________________________

Home address:

________________________________________ ________________________________________ _______________________________________________________________ ____________________________________________________


______ 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 Black Caribbean Other 4. School/College information - If you are at school or college : Name of school/college: _____________________________________________________________ Year group: _________________School/college email :____________________________________ White British Black African White European Black other White other Asian

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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 should we 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 & Premises ii) Fellow Users and Members iii) Staff and Helpers 2) 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 excluded from 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 are not engaged in an organised activity.
I declare that the information on this form is correct. I fully understand the declarations above and accept that it is my responsibility to inform the project of any changes to details contained on this form including any changes in medical conditions or disability status.

Signature of Applicant _________________________________

Date: ___/____/____

Data Protection (Jersey) Law 2005 declaration :

The information collected from you on this form, and any finger scan or webcam image, will only be used for the purposes of administration and monitoring of your Youth Service membership and will not be disclosed to anyone else unless required by law, it is a medical emergency or by getting your agreement beforehand. La Motte Street Studios use bulk mailing to update members with project information Your signature above agrees to this practice using your given email address

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AUG 2013