East Sussex Music Centres Application Form
East Sussex - September 2019 to March 2020
01
Application
02
Tuition fees & subsidies
03
Agreement
I wish to apply for Music Centre Membership
Pupil's Details
Child's First Name
Child's Last Name
Child's Date of Birth
Child's Gender
Male
Female
Unspecified
Child's Ethnic Group
White - English / Welsh / Scottish /Northern Irish / British
White - Irish
White - Gypsy or Irish Traveller
Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Any other Mixed / Multiple ethnic background
Asian / Asian British - Indian
Asian / Asian British - Pakistani
Asian / Asian British - Bangladeshi
Asian / Asian British - Chinese
Any other Asian background
Black / African / Caribbean / Black British - African
Black / African / Caribbean / Black British - Caribbean
Any other Black / African / Caribbean background
Arab
Any other ethnic group
Which School does your child attend?
Class Name
Current Year Group
Is your child a 'looked after child'? This includes children looked after by the local authority, for example with foster carers
No
Yes
Does your child have any special educational needs, disability, or medical conditions that we need to know about?
No
Yes
Please describe
Parent/Carer Details
Title
Name
Address
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua & Deps
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
British Virgin Islands
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
St Kitts & Nevis
St Lucia
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Other
Email
We will use email as our first point of contact with you
Phone Number 1
(home, work or mobile)
Phone Number 2
(home, work or mobile)
Emergency Contact Phone Number
(home, work or mobile)
East Sussex Music is committed to ensuring that instrument and vocal learning opportunities are available to all children and young people in the county.
If your child has any additional or educational needs, including a disability, and you would like to discuss how we can best meet them, please contact the office on 01273 261540 or esm@brightondome.org
Music Centre Membership
• Young Music Makers (reception-year 3 depending on the centre): £21.00 per term
• Junior Choir (years 2-5): £42 per term
• Youth Choir (years 6-13): £42 per term
• All other Music Centre groups and ensembles: £75 per term
Full Music Centre membership enables young musicians to attend any appropriate classes and ensembles and is open to musicians up to 18 years of age.
Which activities would you like your child to learn?
Young Music Makers - *go straight to
Area Music Centre Locations
All other music centre groups and ensembles
Which music group or ensemble would your child like to play in?
Which instrument does your child play?
How long have they played this instrument?
At what standard does your child play
Don't know / n/a
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6+
Name of your child's music teacher
If your child plays other instruments and/or takes part in other music activities, please give very brief details below
Area Music Centre Locations
Which Music Centre would you like your child to attend?
Eastbourne Music Centre
Hastings Music Centre
Lewes Music Centre
Wealden Music Centre
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Fees
Online payments can be made on the website at www.eastsussexmusic.org
Pupils from low income families can get assistance with fees.
Find out if you are eligible for a discount.
Are you eligible for a discount?
No
Yes, I already receive discounted fees - please apply this to my Music Centre charge
Yes, I would like to apply for discounted fees
Please select which discount you are applying for:
25% assistance
Additional assistance and my child is registered for Free School Meals due to financial
circumstances
Please attach/upload a scan or photograph of your benefit award here:
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Photography Statement:
East Sussex Music takes photographs or video during rehearsals, concerts and events. These may be used in publicity material including brochures, programmes, in social media and on our website. For full details, please read the full photographic consent information that you can find at the top of the page.
Copy of Please tick to indicate your
agreement
Yes, I give consent to use images of my child
No, I do not give consent to use images of my child
You can remove your consent at any point by emailing esm@brightondome.org
As a registered charity, East Sussex Music (part of Brighton Dome and Brighton Festival) is able to benefit from Gift Aid on membership subscription group activities. Gift Aid provides vital additional funds for charities, and it costs you nothing extra to allow East Sussex Music to claim it. If you are a UK taxpayer you could increase the value of your subscription at no cost to you. By agreeing to Gift Aid we can claim 25p for every £1 of the membership cost/fee from HM Revenue and Customs.
All of the tax relief from Gift Aid will go directly back into East Sussex Music to provide even more music-making opportunities for young musicians in the city.
Please treat as Gift Aid donations all qualifying subscriptions I have ever made or will make to East Sussex Music /BDBF until further notice
Gift Aid - please tick to confirm
I agree
I am a UK taxpayer and I can confirm I have paid or will pay an amount of Income Tax and/or Capital Gains Tax for each tax year (6 April to 5 April) that is at least equal to the amount of tax that East Sussex Music/ BDBF will reclaim on my gifts for that tax year. I understand that other taxes such as VAT and Council Tax do not qualify. I understand that ESM/BDBF will reclaim 25p of tax on every £1 that I give.
I am a UK taxpayer - please tick to confirm
I agree
Please notify ESM/BDBF if you: want to cancel this declaration; change your name or home address; no longer pay sufficient tax on your income and/or capital gains.
In accordance with the 1998 Data Protection Act and the Privacy and Electronic Communications Regulations 2003, and from May 25th 2018, the General Data Protection regulation (GDPR) 2018, ESM/BDBF will hold your details for administrative purposes and to provide you with updates about our work and how you are helping us change lives through music.
Ending Your Contract
You can only end the contract for lessons at the end of a term. Tell the East Sussex Music office in writing by the date below:
1st December to stop at the end of the autumn term (late December)
1st March to stop at the end of the spring term (late March / early April)
1st August to stop at the end of the summer term (late July)
If you miss these dates, you will need to pay the full term's fees.
Lessons continue from one academic year to the next and *this applies even if your child is changing schools*.
We can't accept verbal notification - please email your request to the music service office NOT the teacher / school. When the lessons stop you must return hired instruments to the teacher.
Agreement
This is a legal contract dated from the time you click Send Email below By entering your full name below, you are confirming that you wish your child to have lessons with East Sussex Music and that you have read and agreed to the terms and conditions (see below)
Terms and Conditions
I have read the terms and conditions
I agree
Full Name
Preview Submission
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