CONFIDENTIAL Registration Form for Alter Ego Participant Name Participant Date of Birth \ \ School/College (if applicable) Area of interest (circle/delete Music/Dance/Other-please specify Please support the work of the Hackney Empire by providing your ethnicity and gender information as required by our funders. Your information is important to us and help to contribute to our future programme. Many thanks. Black/Black British Ethnicity African Caribbean Black/Black British background Please describe Asian/ Asian British Ethnicity Indian Bangladeshi Pakistani Chinese Other Asian/Asian British background Please describe Ethnicity White and Black Caribbean White and Black White and Other mixed/multiple Background African Asian Please describe White Ethnicity British Irish Gypsy/Irish Traveller Other White Background Please describe Other Ethnic Groups Arab Other Please describe Gender Male Female Prefer not to say Your contact details: Address Post Code Email Address: Mobile Parent/Carer /Emergency Contact Details Name
Participant Name Participant Date of Birth \ \ School/College (if applicable) Area of interest (circle/delete Music/Dance/Other-please specify CONFIDENTIAL Registration Form for Alter Ego Please support the work of the Hackney Empire by providing your ethnicity and gender information as required by our funders. Your information is important to us and help to contribute to our future programme. Many thanks. Black/Black British Ethnicity African Caribbean Black/Black British background Please describe Asian/ Asian British Ethnicity Indian Bangladeshi Pakistani Chinese Other Asian/Asian British background Please describe White and Black Caribbean White and Black African White and Asian Other mixed/multiple Background Please describe Ethnicity White Ethnicity British Irish Gypsy/Irish Traveller Other White Background Please describe Other Ethnic Groups Arab Other Please describe Gender Male Female Prefer not to say Your contact details: Address Post Code Email Address: Mobile Parent/Carer /Emergency Contact Details Name