Play/Ground Apply now to take part in Play/Ground by completing this booking form. Ellen will be in touch with you by April 30th to confirm if you have a place.We would love it if you could complete our anonymous equal opportunities monitoring form. This helps us make sure our programmes are as inclusive as possible. Name * First Name Last Name Age * Pronouns Full Address * Phone * (###) ### #### Email Why do you want to get involved in the Play/Ground sessions? * 2 sentences to let us know why you want to come Think of a garden or green space you love. What makes it special? * 2 sentences to tell us your ideas Access We particularly welcome young people to get involved who may have faced barriers to accessing creative opportunities such as this one. Let us know if you have lived experience of any of the following (*You’re disabled or learning disabled under the Equality Act 2010 if you have a physical or mental impairment that has a substantial and long-term negative effect on your ability to do normal daily activities.) Neither of my parents attended university I would describe myself as having a Global Majority identity I am a refugee and/or asylum seeker I am a young carer I am or have been in care Me or my family receive Universal Credit I have a disability* I have a learning disability and/or I have special educational needs* I am a young parent Prefer not to say Support Tell us about any support or access you might need for you to take part in the workshop. For example, needing level access to buildings or a quiet space available. The Old School (Y Hen Ysgol), Crickhowell, has accessible, gender neutral toilets and level access. OR, if you'd rather speak to a member of staff, please contact ellen@peak.cymru to arrange a phone call. Please tell us of any relevant health needs and/or dietary requirements you have. For example, allergies, taking medication. Travel How will you be traveling to the workshops at The Old School, Brecon Rd, Crickhowell NP8 1DG? Do you need any support with this? Parent/carer consent Name of parent/carer * First Name Last Name Address * Phone * (###) ### #### Email * Consent Required Consents * I give permission for the above-named young person to participate in Peak Cymru’s Play/Ground sessions held at the Old School, including any local trips and related events (full details for each session/event will always be shared in advance). If it becomes necessary for the above-named young person to received medical treatment and I cannot be contacted to authorise this, I hereby give my general consent to any necessary medical treatment and authorise the worker in charge to sign any document required by the health authorities. If the above-named young person is deemed unfit to participate (for example, if they are unwell, under the influence of substances or being a danger to themselves or others) in any part of the programme, or leaves an activity without permission, I agree to make immediate arrangements for them to leave the project site until agreed with the staff that they are fit to return. I give permission for the use of photos, video or sound recording featuring my child to be used by Peak, funders and organisational partners in this project on websites, social media, printed publications, news media and evaluation materials. If you have any questions or concerns about media consent, get in touch. * Yes No Each participant will receive a £30 bursary for each session they attend to cover any travel expenses, packed lunch and their time that they are giving to the project. We will collect bank details at the first session. How we use your information: We will always store your personal details securely. We'll use them to support your participation as requested and communicate with you in the way(s) that you have agreed to. Your data may also be used for evaluation purposes, to help us develop future projects. I agree that any information provided on this form, during the project/course can be used by Peak Cymru and shared with other organisations working with them to help deliver, fund and evaluate our programmes, and for the benefit of my welfare, safeguarding or future journey. I understand I have the right to ask to see information held about me by Peak Cymru. For further information about how Peak Cymru uses your information please ask a member of staff. Thank you! Ellen will be in touch to confirm your place and check if you have any questions by Tuesday 30 April. We look forward to seeing you at our first session on Saturday 11 May.
