Skip to content
Enter Search Terms:
Amount to Donate £
Thank you. Your donation has been added to your basket.
Sorry there was an issue with your donation. Please try again. If the problem consists please contact us.
Mobile Navigation Icon
Creative Connections Registration Form
In this form we ask for some information about you. We ask for this information for three reasons:
– To get a head start on understanding your needs so that we can work safely together
– To get the contact information we need to be in touch with you
– To help you with the evaluation of our project.
We (and our funders) want to know if we are making a difference. By gathering information when you join us, we can understand better how you feel in your community and the aspirations you have. At intervals throughout the year we can track your journey and get an idea of whether our organisation is meeting its aims. This evaluation process helps secure future funding.
Name of person completing the form (if the form is not being completed by the person named above):
Your date of birth (or tell us your age if you don't know):
Address Line 2
ZIP / Postal Code
A contact email address (for you or a main carer):
A contact telephone number (for you or a main carer):
It will take time for us to get to know you and we look forward to doing this at your pace. Here is an opportunity for you to give us some information about your needs to start this process. This information is helpful but you are not obliged to tell us anything that you are uncomfortable with.
Tell us about your primary areas of need (tick as many as you wish):
Social and emotional
Anxiety and depression
Moderate learning difficulty
Severe learning difficulty
Other learning disability
If you would like to, please tell us about any other additional needs (including any relevant challenging behaviours) here:
If you would like to, tell us here about any other information it might be useful for us to know (eg your education history, any social care you access, who supports you):
At this time, it is helpful for us to know whether you have had a Covid vaccination. Please tick the box that applies:
Yes I’ve had ONE dose of the COVID-19 vaccination
Yes I’ve had TWO doses of the COVID-19 vaccination
No I have not had any doses of the COVID-19 vaccination
Photo and filming permissions
The Northcott Theatre uses images of project participants, with their consent, for several purposes. This can be to track an individual’s journey, update our followers on social media or promote particular event. The photo consent form gives you complete control of whether your images are used and how. To comply with General Data Protection Regulation 2018, we need your permission before we can photograph or capture any film or audio footage of you. Please answer the questions below, then sign and date the form where shown.
We may take photographs, audio and film footage of you while you are working with Exeter Northcott Theatre to help promote our work on our website, social media and in marketing or funding materials.
We would like your consent to take photos, audio and film footage of you and use them in the way is described above. If you’re not happy for us to do this, that’s no problem – we will accommodate your preferences. Please tick your answer to confirm.
If you change your mind about us taking, storing and using your photograph, audio or film footage at any time you can let us know by emailing email@example.com.
I give permission for my photograph and any audio and film footage to be used for display purposes
I give permission for my photograph and any audio and film footage to be used during presentations about the Northcott’s work
I give permission for my photograph to be used in printed materials promoting Northcott Theatre’s services and for fundraising events, campaigns and appeals
I give permission for my photograph, audio and film footage to be used on Northcott Theatre’s website
I give permission for my photograph, audio and film footage to be used on Northcott Theatre’s social media sites (e.g. Facebook, Instagram and Twitter)
I give permission for my photograph, audio and film footage to be shared with the local and national media to help raise awareness of Northcott Theatre’s work
Signature (type your name)
MM slash DD slash YYYY
We like to check in on participants of our projects from time to time to record what you think of our programmes and to ask what’s going well for you and what we could do differently.
If you are completing this form on behalf of someone who does not use verbal communication, how best can we record their experiences? (E.g. photos, videos, facial expressions, advocacy from family members)
Access and Facilities
Getting Here – Exeter Northcott Theatre
Get Creative Commissions
Young Creatives Programme
Our History & Heritage
Diversity & Inclusion
Work With Us
Hire Our Space
Info for Visiting Companies