Alter Ego Registration 2017 Alter Ego 2017 Question Title * 1. Personal Details w 0 Full Name Date of Birth Address Address 2 City/Town Postal Code Country Email Address Phone Number Question Title * 2. If you are auditioning as part of a group please fill out the below information w 0 Name of Group Number of participants in the group Are you the lead contact for the group? Question Title * 3. Area of interest w 0 Dance Music Other (please specify) Question Title * 4. How did you find out about Alter Ego? w 0 Web Friend Email School Teacher Other Other (please specify) Question Title * 5. Your ethnic and gender information is required by our funders. Please select the appropriate box, thanks! w 0 Albanian Arab Bangladeshi Black African Black British Black Caribbean Chinese Gypsy / Roma Indian Iranian Iraqi Latin/South/Central American Other Asian background Other black background Other mixed background Other white background Pakistani Traveller Turkish White and Asian White and black African White and black Caribbean White British White European White Irish Prefer not to say Question Title * 6. Gender w 0 Male Female Question Title * 7. School/ Youth Group Details (where applicable) w 0 Contact Teacher/ Group Leader School Address Address 2 City/Town ZIP/Postal Code Phone Number Question Title * 8. Parent/ Carer/ Emergency Contact Details w 0 Name Relationship to student Address City/Town ZIP/Postal Code Email Address Phone Number Question Title * 9. The auditions will take place on the 8th April-please let us know if you would prefer a morning or afternoon audition, we will do our best to accommodate you. w 0 AM audition PM audition No preferance Question Title * 10. Do you have any medical conditions/disabilities/access requirements? w 0 Question Title * 11. Would you like to hear about future Creative Learning Opportunities at Hackney Empire? w 0 Yes- I am happy to be contacted by Hackney Empire about further opportunities No Question Title * 12. PARENTAL /GUARDIAN CONSENT FOR U-16s // PERSONAL CONSENT FOR 16+I consent for the above participant to take part in Alter Ego 2017.I consent to the use of all audio and visual recordings of the above participant for the purpose of marketing and evaluation here at the Hackney Empire. w 0 By selecting this box you agree to the above statements I do not consent or can not give consent as this time Done