IRIE! dance theatre's Autumn Programme registration form

IRIE! Registration Form

Please complete this registration form for EACH participant of an IRIE! class

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* 1. About you

First Name

Surname

Post Code

Telephone Number

Email Address

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* 2. Age?

8 - 17

18-25

26-35

36-45

46-55

56-65

65+

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* 3. Gender?

Female

Male

Prefer not to say

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* 4. Which Activity are you participating in?

Dominoes

Tai Chi

Women's Dance/Exercise

Vintage Tea

Heritage

Family Fun Day

Other (please specify)

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* 5. Have you ever visited The Moonshot Centre before

Yes (what was the nature of your visit?)

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* 6. How did you find out about us?

Word of mouth

Friends or family

IRIE! Newsletter

Instagram

Facebook

IRIE! website

Newspaper or leaflet

Another provider

Other (please specify)

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* 7. Would you like to opt in to hear about more exciting events and opportunities by signing up to IRIE!’s mailing list? You can withdraw your consent at any time by emailing info@iriedancetheatre.com

Yes

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* 8. From time to time, IRIE! Will use pictures or videos of our workshops and activities to promote our services via our websites, on publicity posters or in our publications.

I grant IRIE! Dance Theatre full rights to use images resulting from the photography/video filming, and any reproductions or adaptations of the images for fundraising, publicity or other purposes to help achieve the group’s aims. This might include (but is not limited to), the right to use them in

Yes

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* 9. Which race/ethnicity best describes you? (Please choose only one.)

Asian or Asian British – Indian

Asian or Asian British – Other

Black or Black British – African

Black or Black British – Caribbean

Black or Black British – Other

Chinese

Mixed - Other

Mixed – White and Asian

Mixed – White and Black African

Mixed – White and Black Caribbean

White – British

White – Irish

White – Other

Prefer not to say

Another race or ethnicity (please specify)

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* 10. Do you consider yourself to have a disability or health condition?

Yes

Prefer not to say