· web viewelectric umbrella are challenging the perception of people with learning...

Electric Umbrella Application Form

Season Dates and Details: The Electric Umbrella autumn season runs from September to December 2016. Each season at Electric Umbrella includes weekly sessions, touring opportunities and free access to the main events. Nearer the time we will publish the session dates and times. Please also regularly check our website at electricumbrella.co.uk.

Securing your place: If you would like to secure a place for the autumn season please return a completed application form and make a minimum payment of £200 by the 29th July. Places will be confirmed upon receipt of completed application and payment. For any other enquiries relating to your application please contact us. Completed application forms can be returned by post or email to the address below.

Why a minimum donation: The running cost of each season is significantly subsidised by fundraising and we would welcome a higher donation if you would like to contribute more to Electric Umbrella.

Contact Details:Postal address: Electric Umbrella, c/o 29 Belham Road, Kings Langley, Herts, WD4 8BX. Email address: [email protected] Number: 07779 065 185

Payment Details:Payments can be made by cheque payable to Electric Umbrella and posted to the above address, or by Bank Transfer/BACS Account Number: 43284043 Sort Code: 600008.

Keeping in Touch:Electric Umbrella will keep contact with parents and PA’s via email regarding additional opportunities and events outside of the regular sessions. If you are not able to receive this information via email, or would like it sent to more than one email address, please advise on the form below. Please add [email protected] to your ‘address book’ or ‘safe senders’ list to ensure you receive this information.

Electric Umbrella are challenging the perception of people with learning disabilities by empowering and enriching lives through music.

REGISTERED CHARITY NO. 1165164

mailto:[email protected]

mailto:[email protected]

Should you need to make contact with Electric Umbrella during session times, or at any other point, you can do so on the mobile number as above.

You may also wish to keep up to date by becoming a member of our Facebook group, ‘Electric Umbrella Members’.

Additionally, Electric Umbrella events will be announced on social media. Like ‘Electric Umbrella’ on Facebook, follow @electricbrolly on Twitter and follow ‘Electric Umbrella Charity’ on Instagram.

Personal Details:The information required on this form will ensure that Electric Umbrella are able to meet the needs of all members and plan the necessary support for each individual to reach their full potential during sessions.

Electric Umbrella expects to be informed and kept up to date with any changes to the information disclosed.

All information submitted will remain confidential for use by relevant Electric Umbrella personnel only and not be shared with third parties except where there is a legal requirement for disclosure or in the case of a medical emergency where it will be shared with medical staff if PA’s/supporters are unable to attend soon enough. We will use the data for the planning of sessions. We will use contact details to send you details of weekly sessions and opportunities at Electric Umbrella. We will use the details to send you news about Electric Umbrella and forthcoming events you may be interested in. This document will be stored securely in accordance with the Electric Umbrella data protection policy and not be kept longer than necessary.

Full Name:

Date of Birth:

Address:

Contact Telephone:

Email Address:



Please select the group you wish to attend:

Monday - HEMEL (Old Town Hall)

Thursday - WATFORD (Merchant Taylor’s School)

Friday - RICKMANSWORTH (Roundspring Farm)

Name of primary PA/supporter:

PA/supporter email address:

PA/supporter contact number during sessions:

Name/relationship of Next of Kin:

Next of Kin contact details:

In some circumstances it is necessary for a PA/supporter to be in attendance throughout the session, and in others it is more appropriate for the member to be left on their own. Please detail your preference below, and this will be discussed on receipt of application.

PA/supporter in attendance YES / NO

Medical Information:

Please detail any medical information, and general details of disability.



Please state general details regarding the following:

- Speech

- Eyesight

- Hearing

- Mobility

- Communication

- Medication

Do you suffer from epilepsy? YES/NO

(If so, please detail protocol.)



Please detail of any allergies e.g. medicine, food and bites, and known treatment.

Please detail any dietary requirements.

Please detail anything that the member may require assistance with during sessions and if support will be provided e.g. Personal care.

Please detail any other information you feel is necessary to enable us to do our best to accommodate everyone’s needs, and ensure the welfare of other participants and staff at the session.



Please detail any criminal convictions, warnings, cautions or reprimands.

Declaration and Disclaimer:

Terms and Conditions

Payment for sessions is due in advance, for each season. (N.B. This is still payable over weeks of illness/absence.)

Where possible, Electric Umbrella encourages members to attend sessions without a PA/supporter. This enables maximum inclusion and integration in the group, and friendships to form. This will be discussed on a case-by-case basis upon receipt of each application. Should a PA/supporter be required, they must remain in the room throughout the session and support Electric Umbrella to enable the member to engage as fully with the session as possible. If a PA/supporter needs to be nearby but not in the room, the PA/supporter must make sure to inform Electric Umbrella staff where they will be, and provide a mobile contact number at the start of each session.

Electric Umbrella will ensure that each member is able to participate as fully as they can, from the start time of the session, until they leave the premises at the end of the session. Electric Umbrella will not take responsibility for routine medical and personal care during session times, or personal welfare outside of session times.

Members are not the responsibility of Electric Umbrella staff until the session commences.

Any necessary medical or other information regarding the welfare and safety of members and staff must be included on the application form, and discussed where necessary.

Electric Umbrella will not take responsibility for anything not covered on this form.

At least 2 members of Electric Umbrella staff will be present at each session.

Electric Umbrella will take a number of photographs and videos to be used in promotional material and social media. Please indicate whether permission is granted for us to do so.Photo consent - YES / NO

On occasion, Electric Umbrella members will travel offsite by minibus/car for performance or other opportunities. PA’s/supporters will always be notified of these trips in advance. Please confirm below to confirm that travel is permitted.Travel consent - YES / NO



I agree to the above terms and conditions, and declare that the information provided is complete and true. I understand that if I fail to disclose the relevant information or give false information that it may lead to the participation at Electric Umbrella being terminated. The accuracy of this data is the responsibility of the PA /supporter and it is their responsibility to update Electric Umbrella when necessary.

Name _____________________________________________________

Signed ___________________________________________________ Date ___________



· web viewelectric umbrella are challenging the perception of people with learning...

Documents