Family Sign up in person – Literacy Pirates

Literacy Pirates Registration Form 2021-22

Your Child's Details

First Name

Last Name

Home Address

Postal Code

City

Date of Birth

Year Group 2021-22

School

Will your child be attending our Primary or Secondary sessions?

PrimarySecondary

Please choose the day that you would like your child to attend The Literacy Pirates sessions. Please note that there will be no Hackney sessions on Wednesdays.

Primary - Day Choice 1

Please choose the day that you would like your child to attend The Literacy Pirates sessions.

Secondary - Day Choice 1

Please provide 3 contacts for your child, in the order we should call if we need to contact you.

Contact 1

First Name

Last Name

Relationship to Child

Phone Number

Contact 2

Full Name

Relationship to Child

Phone Number

Contact 3

Full Name

Relationship to Child

Phone Number

Travel arrangements FROM The Literacy Pirates - Please select all options that apply.

My child has permission to travel from The Literacy Pirates alone.

YesNo

My child will be accompanied by:
(Tick all that apply)

MotherFatherSiblingCarerOther Family MemberFamily Friend

Other (please specify)

We are keen to ensure that we are providing equal opportunities for all. The following information will be treated as confidential.

Gender

First Language

Ethnic Group. Please choose from one of the following:

Arab	Asian (Indian, Pakistani, Bangladeshi, Chinese)
Asian British	Asian Other
Black African, Caribbean	Black British
Black Other	Kurdish
Latin American	Mixed Black, White
Mixed Other	Turkish
White British	White Other
Other	Prefer Not to Say

Is your child eligible for Pupil Premium funding?

YesNo

Does your child have special educational needs?

YesNo

If yes, please provide details

Does your child suffer from any allergies?

YesNo

Details, including medication given (please be specific)

Does your child have any medical conditions?

YesNo

Details, including medication taken (please be specific)

Is there any other information useful for us to know (educational/social/emotional/behavioural)?

Learning Sessions

I give permission for my child to attend The Literacy Pirates After-School Sessions and consent to my child working with Literacy Pirates staff and volunteers.
I acknowledge that my child needs to attend the weekly sessions they sign up to, and that I must give at least 3 hours’ notice of cancellation if they are unable to attend.
I support good behaviour in sessions and will discuss any issues with Literacy Pirates staff.
I give permission for short trips in the local area, accompanied by Literacy Pirates staff and volunteers.

Publishing

I give non-exclusive licence for The Literacy Pirates to use the contributions of my child (which my child owns the rights to) towards their charitable aims, granting consent required by law for their use both now and in the future.
I waive and agree not to assert, any so-called “moral rights” or other non-transferable rights that I may have in relation to the contribution as my child will be given suitable author credit.

Library

I understand that if my child does not return books to The Literacy Pirates Library that they may be stopped from borrowing books. I will report any books my child loses.

Evaluation

I agree to contribute to The Literacy Pirates Monitoring and Evaluation strategy by completing termly questionnaires about my child’s progress.

Privacy

I agree to The Literacy Pirates privacy policy, which is available at www.literacypirates.org .
I understand they will never sell my information or the information of my child.
I understand that they collect information to support my child on the programme and that information that will help support my child is shared between school and The Literacy Pirates.

Photo Permission

I give permission for photographs and video footage of my child to be used by The Literacy Pirates for the learning programme and for their charitable aims, in both displays and online on our website and social media (Twitter, Instagram, Facebook).

***This will include their photo being used/included in our Young Pirate products, such as our published book and movie. If you have any special requirements regarding photo consent for your child, please get in touch. We will record them and ensure they are met. You can reach us at 07912 178037.***

Consent and Agreement

I consent to the above Terms and Conditions

Yes

I give Photo Permission

YesNo

Signed (Full Name)

Relationship to child:

Date

Contact Information

Literacy Pirates Registration Form 2021-22

Please provide 3 contacts for your child, in the order we should call if we need to contact you.

Contact 2

Contact 3

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