Student’s name…………………………………………………………………………………………………

Students date of birth and current age……………………………………………………………..

3 forms of identification provided and copied and signed by Melanie Ash (1 photographic)

1)………………………………………………………………………………………………………………………

2)………………………………………………………………………………………………………………………

3)……………………………………………………………………………………………………………………..

Have you any criminal convictions relating to violence or sexual abuse? ……………………………………………………………………………………………………………………………………………

Have you ever been investigated due to an allegation relating to sexual or physical abuse against children or vulnerable adults?

……………………………………………………………………………………………………………………………………………

Are you known to child protection teams in the local authority?

……………………………………………………………………………………………………………………………….

PLEASE TICK BOX AND SIGN

I give permission for Meladrama to use this information to check my identity against the electoral roll.

I give permission for Meladrama to ask for clarification from relevant authorities in line with their safeguarding policy if required and with my prior consent.

I support Meladrama’s safeguarding policy and declare that I won’t contact any students that are under the age of 18 or vulnerable outside of class.

SIGNED………………………………………………………. DATE………………………………………………………………