CHAPERONE/S IN CHARGE: …………………………………………………………. DATES OF PERFORMANCE: FROM………………………………….. TO ………………………………….. Name of Child Emergency Contact Name & Telephone No. Children Missing Education Service, People & Communities Department, lewis House, Manvers Street, Bath BA1 1JG Tel: 01225 394241 CHAPERONE REFERRAL FORM This form is for use of Chaperones who wish to note with the licensing LA any concerns encountered whilst chaperoning child/children performing in: films, TV, modelling, commercials, theatre, sport or any other performance falling within the Children (Performance) Regulations 1968 and subsequent statutory instruments. Chaperone Name Chaperone Contact
CHAPERONE/S IN CHARGE: …………………………………………………………. DATES OF PERFORMANCE: FROM………………………………….. TO ………………………………….. Name of Child Emergency Contact Name & Telephone No. Children Missing Education Service, People & Communities Department, lewis House, Manvers Street, Bath BA1 1JG Tel: 01225 394241 CHAPERONE REFERRAL FORM This form is for use of Chaperones who wish to note with the licensing LA any concerns encountered whilst chaperoning child/children performing in: films, TV, modelling, commercials, theatre, sport or any other performance falling within the Children (Performance) Regulations 1968 and subsequent statutory instruments. Chaperone Name Chaperone Contact