6 Eunice Grove, Chesham,

Buckinghamshire HP5 1RL

Telephone: 020 8952 6010
Email: chrystelarts@waitrose.com

MEDICAL CONSENT
To be signed by a parent for students under 16 years, or by the student themselves if over 16 years.
Any information provided on this form is strictly private and confidential and for internal purposes only.

Name of pupil:

I, ________________________________________, being parent/guardian of the above named child*

give permission for an authorised Chrystel Arts representative to give the immediate necessary authority on
my behalf, for any medical or surgical treatment recommended by competent medical authorities, where it
would be contrary to my/child’s/ward’s interest, in the doctor’s medical opinion, for any delay to be incurred
by seeking my personal consent.

NB: Please note that a young person can give their own consent for medical treatment if they are over 16
years old.

Signature: Date:

(consent by student/parent/guardian) *Please delete if signing on your own behalf.

PHOTOGRAPHIC CONSENT
As part of the teaching and performance programme, photographs may be taken and used in a range of print
and promotional material. Please note that photographs may be kept for an indefinite period and may not be
used immediately. Under the Data Protection Act 1998, this information will not be used for any purpose
other than that stated on the form.

If you do not wish your son/daughter to be photographed - please tick the box: ■
PAYMENT
This form must be completed and returned, with the deposit for two trial classes, before attending any
classes, together with a signed copy of the School’s Terms and Conditions and Enrolment form.

Signature: Date:

Pupil’s name:

I enclose a payment of : £ Cheque / Cash

Please note that all information provided will be used to create a confidential computer and manual based
file, the use of which complies with the provision of the Data Protection Act 1998.

CA-08/16