2 Full Time Course Application continued

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2 2 Full Time Course Application continued Please attach additional sheet(s) of paper, where required. Please note that all information contained in this form will be treated in strictest confidence and not released to anyone outside Urdang. Performing Arts/Dance Education Subject (eg Ballet, jazz, singing, acting) Syllabus / Style Yrs of training Most recent exam Result Date taken Please state any dance / performing arts training and certificates gained. Only state the highest level achieved in any subject. If exam has not been taken or you are awaiting results, please state. Musical instruments Performing experience Academic Education Subjects Exam type (GCSE, A Level, etc) Result Date All school examinations passed and those to be taken within current academic year, or where results are pending. Schools Attended Name and address of school Entry date Leaving date Include current Dance and Academic schools. Parent/Guardian consent required for applicants under 18 years old. I confirm that to the best of my knowledge, the information on this application form is correct and that I am physically fit and well enough to take the audition if required. Signature of Applicant Date I, the Parent or Guardian, approve and give consent to this application. Signature of Applicant Date

3 3 Medical Questionnaire Full Name Date of Birth 01 Do you have any record of broken bones, serious muscle/ligament or spinal injuries? Yes No If yes, dates and details of treatment 02 Do you have any record of serious diseases, blood disorders or heart conditions, e.g. polio, rheumatic fever, glandular fever, diabetes? Yes No _ 03 Do you have any record of hay fever, eczema, allergies or skin conditions? Yes No 04 Do you have any record of eye or ear problems? Yes No 05 Do you have any record of any serious operations? Yes No 06 Have you any history of migraine, blackouts, epilepsy or asthma? Yes No 07 Have you any history of depression, anxiety states or other nervous disorders? Yes No

4 4 Medical Questionnaire continued 08 Are you currently taking any medication or drugs? Yes No _ 09 Do you have any record of eating disorders? Yes No _ 10 Do you have either dyslexia/dysphasia or any form of learning disability? Yes No 11 Are there other medical details not covered above that could affect full-time training? Yes No I declare that, to the best of my knowledge, the information given in this medical form is complete and correct. Signed by the Applicant: Signed by Parent / Guardian if under 18 years: DOCTOR: contact information and declaration (only to be completed on enrolment). Doctor s / Practice name: Practice Tel No: This is to certify that the above named is a patient of mine and is currently fit and well. He / she has no injury, illness or medical condition which should prevent him / her from undertaking full-time dance training. Signed: Date:

5 5 Equal Opportunities Form This form is not compulsory, but does help us with information required by governing bodies. The information provided in this form will be treated confidentially and will be used only for monitoring purposes by Urdang Schools Ltd. No information which could be used to identify an individual will be released to any external party. Full Name Date of Birth Gender Male Female Do you have disabilities? Yes No Have you chosen to register your disability? Yes No My nationality is UK EU Other (please state) I consider my ethnic background to be: Asian or Asian British - Bangladeshi Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Any other Asian background Black or Black British - African Black or Black British - Caribbean Black or Black British - Any other Black background Chinese Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Caribbean Mixed - Any other Mixed background White - British White - Irish White - Any other background Not known Not provided Any other I declare that to the best of my knowledge, the information on this application form is correct. Signature of Applicant Date Signed by Parent / Guardian if under 18 years

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