2016 - 2019 Application Form

Please fill out all sections of this form in BLOCK CAPITALS or ask a parent/support worker to help.

Return to: Blue Teapot Theatre Company, Munster Avenue, Galway or email .

APPLICANT NAME:
ADDRESS:
TELEPHONE NUMBERS: / Home:
Mobile:
Emergency:
PERSONAL INFORMATION / Date of Birth: ______
Nationality: ______
PPS No: ______
EMAIL ADDRESS:
NAME of PARENT/GUARDIAN:
Relationship to applicant:
ADDRESS:
TELEPHONE NUMBERS: / Home:
Mobile:
NAME & PHONE OF SOCIAL WORKER:
NAME & PHONE OF KEY WORKER:

§  Blue Teapot Performing Arts School training is specially designed to support the creativity of adults with intellectual disabilities.

§  To be eligible for our programme, applicants must have an intellectual disability.

§  In order to support a learner’s individual needs, please tick the relevant boxes that apply and any specific information.

§  Important: Successful candidates offered a place in the school is on condition that information provided here is a correct and accurate assessment of an individual’s mental and physical health and is fully disclosed to Blue Teapot Theatre Company.

TICK all that apply / LEVEL & NATURE OF DISABILITY / PLEASE PROVIDE MORE INFORMATION
Mild to moderate learning difficulty
Dyslexia or difficulties with reading, writing or numbers.
Hearing impairment/hearing aid
Speech impairment
Visual impairment
Autism Spectrum
Physical or mobility difficulties
Specific medical conditions & on any medication
e.g. Epilepsy, asthma, diabetic
Mental health difficulty
e.g. serious anxiety, depression
Other specific disorder

EDUCATION & EMPLOYMENT HISTORY

Please let us know what your current education, training or employment is.

a□ School □ Day Centre □ College □ Employed □ Unemployed □ Other

______

Please tell us about where you are/were educated, where you have trained, worked, volunteered and list any qualifications you have gained.

SCHOOL ATTENDING:
Qualifications (if any)
DAY CENTRE OR TRAINING PROGRAMMES:
VOCATIONAL TRAINING or COLLEGE ATTENDING:
Qualifications (if any)
CURRENT OR RECENT EMPLOYMENT HISTORY:
VOLUNTEER WORK:

YOUR INTEREST IN PERFORMING ARTS

Please tell us which Performing arts skills you like. Tick all that apply.

a□ THEATRE □ MUSIC & SINGING □ DANCE □ ART & DRAWING □ OTHER

______

Please tell us about any previous performing arts experience you have, if any:
Have you heard about or seen any work by Blue Teapot?
I.e. a show, a parade, viewed our website?
Tell us why you want to join Blue Teapot Performing Arts School?

Thank you for completing this application. You will be contacted soon with regards interview.

Signature of Applicant:
Signature of Guardian:
(if required)
Date: