REGISTRATION FORM – MiX and MiXXtra

This form should be signed both by the young person and a parent/guardian.

You can find out more about how we use your personal data by reading
our privacy notice which you can find at
www.springfieldchurch.org.uk/privacynotice

Full name

Date of birth

Postal address
(including postcode)

Any allergies or medical

conditions/medication?

Parent/guardian’s name

Parent/guardian’s email

Parent/guardian’s
telephone number(s)
Please tick to confirm your consent to one or more of the following*:

◻ I, ___________________________________________________ (parent/guardian name) give permission for

_______________________________________________________ to attend MiX and MiXXtra events.

◻We may contact you to tell you about what is going on at the MiX and MiXXtra. These communications might
also appear on our website and/or the Diocese’s website or on social media.
Other activities and groups
◻We may contact you about youth activities happening more widely at Springfield Church in which you might be
interested.
◻We may contact you about other activities at Springfield Church in which you might be interested.
Keeping in touch:
 Yes, I would like to receive communications by email
 Yes, I would like to receive communications by telephone
 Yes, I would like to receive communications by mobile phone (including by text message)
Young person’s Parent/guardian’s
signature signature

Date

* You can grant consent to all, one or none of the purposes. Where you do not grant consent to communications we will not be able to use
your personal data, (so for example we may not be able to let you know about forthcoming services and events) except in certain limited
situations, such as where required to do so by law or protect members of the public from serious harm. You can find out more about how we
use your data from our “Privacy Notice” which is available at www.springfieldchurch.org.uk/privacynotice or from the church office. You can
withdraw or change your consent at any time by contacting the church office.