Pro Corda

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- Chamber Music Weekends
- Piano Sanctuary
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- Concerts at Leiston Abbey
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About
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Contact
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Courses
Schools
Adult Programme
- Chamber Music Weekends
- Piano Sanctuary
Concerts
- Concerts at Leiston Abbey
Support Us
About
Contact

Outreach Application Form

Step 1 of 5

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We are thrilled your child wants to join us on one of our activity days / weekends. Please provide as much information as possible, to ensure your child’s enjoyment and safety.
What event are you applying for?*
Participant's Name*
First Last
Any Nickname(s)
Date of Birth*

Day
Month
Year
Age*
School College*
Parent / Main Carer's Name*
First Last
Parent / Main Carer's Email*
Parent / Main Carer's Mobile Phone No.*
Home Address*
Street Address Address Line 2 (Optional) City County (Optional) Postcode Country
Home Phone No.*
Emergency Contact
Name*
First Last
Relationship*
Home Phone No.*
Mobile Phone No.*
GP Surgery
Surgery Name*
Surgery Address*
Street Address City County Postcode Country
Surgery Phone No.*

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Health and Medical needs
Diagnosis - please describe your child's condition or disability
What medication, if any, does your child take regularly and how often?
Do they need this medication during the activity day / weekend?
- Yes
- No
- N/A
At what times of day?
Does your child have any major health needs that staff should be aware of?*
e.g. epilepsy, asthma, severe allergies etc
- Yes
- No
Please include full details and send us a Care Plan if appropriate
Is your child technology dependent?*
- Yes
- No
Does your child need to have any emergency medication available at all times?*
e.g. inhalers, epipen, epilepsy medication etc...
- Yes
- No
Please describe the emergency medication required
Are there any activities that your child should not take part in for medical reasons?
e.g. swimming, trampolining, martial arts etc...

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Personal Care and Hygiene Needs
Does your child?
Please tick as appropriate
- Manage own personal care independently?
- Need encouragement or support for personal care?
- Need practical help with care? e.g. pads changing / cleaning up?
- Need to use a hoist and changing bed?
- (Girls) Need help with menstruation?
Please give more information if applicable
Mobility
Does your child?
Please tick as appropriate
- Walk independently?
- Use walking aids?
- Use a wheelchair occasionally?
- Use a wheelchair permanently?
- Use an electric wheelchair?
Please give more information if applicable
Mealtimes
Does your child?
Please tick as appropriate
- Manage mealtimes independently?
- Need supervision or practical help to manage food?
Please give more information if applicable
Does your child have any dietary needs relating to serious allergies or medical conditions?
e.g. no nuts, gluten-free diet. Please give details...
Communication and Sensory Needs
Does your child?
Please tick as appropriate
- Have a sensory impairment? (Sight / hearing etc...)
- Have good verbal skills?
- Use other methods of communication (BSL / Makaton / Communication Aid, PECS)?
Please give more information if applicable

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Behavioural and Emotional Needs
Is your child's behaviour generally reasonable for their age?*
- Yes
- No
Identify possible triggers and risks, and describe strategies to manage behaviour.
Can your child be managed in a small group of 3-4 children?*
- Yes
- No
Identify possible triggers and risks, and describe strategies to manage behaviour.
Does your child usually need constant supervision?*
- Yes
- No
Identify possible triggers and risks, and describe strategies to manage behaviour.
Is your child likely to wander or run off?*
- Yes
- No
Identify possible triggers and risks, and describe strategies to manage behaviour.
Is your child aware of danger?*
e.g. water / heights / traffic?
- Yes
- No
Identify possible triggers and risks, and describe strategies to manage behaviour.
Does your child have any strong fears?*
e.g. balloons / dogs etc...
- Yes
- No
Identify possible triggers and risks, and describe strategies to manage behaviour.
Does your child have temper tantrums or other strong reactions?*
- Yes
- No
Identify possible triggers and risks, and describe strategies to manage behaviour.
Is your child sexually aware?*
- Yes
- No
Do they need close supervision when around specific individuals or groups?
Please give details
Is there any more information that would be helpful for us to know?
Please give details

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Parental Consent
I acknowledge that the staff will be liable in the event of any accident only if they have failed to take reasonable care of my child during the activity.
Activities*
I consent to my child taking part in the activities
Behaviour*
I have read the Code of Conduct expected during the activity and I undertake to reinforce this information with my child
Medical*
I agree that staff should take any medical action deemed necessary in the event of an emergency.
Photography and filming
I have read the Pro Corda Photographic Policy and give permission for photos to be taken and reproduced accordingly.
Information*
I give my consent to this information being shared with any organization that will be providing direct care for my child.
We have a strict policy that only allows personal information to be used for limited purposes. We will never sell it or share it with another organisation for their benefit.

Unless indicated below the personal information you provide will only be used and retained in relation to the course or courses applied for, and (if appropriate) to invite students to future courses. If at any time you wish to be taken off our contact lists please email us: mail@procorda.com.
Keeping in touch
Pro Corda is a non-profit making registered charity that relies on support from students, parents and alumni as well as on grant funders and volunteers. We would like to be able to keep in touch with you periodically about our work, including our exciting development plans. We would like to be able to do this by email to reduce costs, but we need your agreement to that.
Please keep in touch about:
- Concerts and events
- Our development initiatives and plans
- I am happy for you to contact me by email about these
Consent*
Please confirm that you give us permission to handle your information. Please review our Privacy Policy for more details.
I agree to the privacy policy.

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Get in Touch

+44 (0)1728 831354

mail@procorda.com

Further Details

All Pro Corda Policies

© Pro Corda 2026
All Rights Reserved Pro Corda Trust: Company No. 05829570 and Registered Charity No. 1116213

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