Comics Corner x Art NightThis is Me Self Referral FormThis project is for young people aged 12-18. If you are under 16, a parent or guardian will need to fill this in for you.If you are a practitioner referring a young person, please do so here. Referred by Where did you hear about the project? Name * First Name Last Name Preferred Name First Name Last Name Gender * (Male, Female, Non-Binary, etc.) Date of Birth * MM DD YYYY Address * Contact Number * Email * How would you like us to contact you? * Phone, text, email, WhatsApp School/College Ethnicity * Medical Conditions * Yes No Disability * Yes No Additional Needs * Yes No If "Yes" to the above, please provide details. Parent/Guardian/Emergency Contact If you are under 16, a parent or guardian must fill out the information below. Name * First Name Last Name Relationship to Young Person * Address Phone Number * Email * Additional Emergency Contact If we are unable to reach your parent/guardian in an emergency, we will try to contact this person instead. Name * First Name Last Name Relationship to Young Person * Address Phone Number * Email * Your Personal Data By signing up for the This is Me project you agree to provide Comics Youth SCIO and Feeling Strong with certain personal information, which we will process in accordance with all applicable data protection laws to: Provide you with services and carry out administration in relation to your membership; Communicate with you and your parent / guardian about your membership; Provide information about your membership to suppliers, funders and/or sponsors as required for the purposes of the development, coordination and support of Comics Youth SCIO. Your Sensitive Personal Data * We may collect sensitive personal information for example, information relating to your health, disability and/or ethnic background. I agree that my sensitive personal information can be processed to provide me with services and carry out administration in relation to my membership. I agree that my sensitive personal information may be shared with suppliers, funders and/or sponsors (as required for the purposes of the development, coordination and support of the Comics Youth SCIO). Comics Youth SCIO will ensure that third parties agree to keep this information confidential. I agree that my sensitive personal information may be shared with Feeling Strong for the purposes of administration in relation to my membership on this project. Your Image * I agree that my image (in photos or videos) may be used for marketing and publicity purposes in printed publications, on social media, on the Comics Youth SCIO or Feeling Strong websites, or elsewhere. Yes No Your Artwork * I agree that my artwork (in photos or videos) may be used for marketing and publicity purposes in printed publications, on social media, on the Comics Youth SCIO or Feeling Strong websites, or elsewhere. Yes No SQA Level 2 Personal Achievement Award * As part of this project you have the opportunity to undertake an SQA Level 2 Personal Achievement Award, supported by Feeling Strong. The award aims to enable you to develop confidence, independence, knowledge and skills for learning, life and work. If you would like to participate, we will send all follow up information via email. Yes No Thank you for signing up to This is Me! We will be in touch within 5 working days to confirm your sign up. Please note, our emails are monitored from Tuesday-Friday.If you have any questions, feel free to email hi@comicsyouthscio.uk.
