Full name of child (required)
Your Email (required)
Number of brothers and sisters
Telephone numbers(s): This must include the numbers of both parents who could be contacted about the child
Who does the child currently reside with?
Mother and Father,Mother,Father,Other
Does your child receive free school dinners?
How are you related to the child?
MotherFatherOther (if other) please state
What is your ethnicity:
IndianPakistaniBangladeshiSomaliOther(if other) please state
Do you or your partner work:
NoOnly I workOnly my partner worksWe both work
If yes, what is your occupation:
What is your partner's occupation:
Has anyone from the immediate family attended university ('immediate' only includes the child's mother, father or brothers and sisters):
If yes please state who and what they studied for their degree:
The teaching sessions will be taking place at the Highfields Community Centre on Sundays between 12.30 - 3pm.* Will you be able to ensure that your child is able to attend on a weekly basis:
The next few questions will not affect your child's application process but are important for us to be aware of in case of an emergency.
Does your child suffer from any medical conditions? [for example asthma/diabetes/epilepsy]
If yes please state what and how if affects your child:
Does your child have any allergies?
If yes please state
Empower Youth AcademyEmpower PO Box 9942 Leicester LE5 9GB