The Children and Young Person Acts 1933 and 1963
The Children (Performances and Activities) (England) 
Regulations 2014
Standard Child Performance and Activities Licence Application Form (England) 
Note: this form should be completed and submitted to the licensing authority not less than 21 days before the first performance or activity for which the licence is requested, since the licensing authority may otherwise refuse to grant a licence.
Part 1: Information to be provided by the applicant about the performance or activities 
Title:
	Name:	
Job title:	Company:
	
Address:

Tel:	Mobile:	
Email:	

1)	Does your organisation have a child protection or safeguarding policy? 
b) When was this last updated?
Please insert a link or attach a copy. 		
 Note: it is best practice that organisations that involve children in performances, paid modelling or paid sport have or develop a child protection policy, regularly review and update it, and ensure that all staff and volunteers are familiar with it. 

2)	Name and nature of the performances or activities in respect of which the licence is requested: 		
		
3)	Please provide as full a description as you can about what the child will actually be required to do. Include information about the environment they will be asked to do it in, and any other contextual information that may help us in assessing the potential risks, physical, emotional or psychological, to the child. 		
4)	If you have completed a risk assessment please attach it to this application. 
See the sector led best practice guidance for further information about risk assessments. 	
	
5)	Place of activities, performances and rehearsal for which the licence is requested, including any periods on location:		
		
6)	The dates and times of activities, performances or rehearsals for which the licence is requested:
If the dates are not known at this time, please provide the number of days and the period during which it is requested that a child may take part in activities, performances or rehearsals.		
		
7)	The expected total running time or duration of activities or performances (including any rehearsal) in respect of which a licence is requested:		
		
8)	The approximate duration of the child’s appearance in the performance or activity:		
	
9)	The amount of night work (if any) for which approval is being sought and please state:	
a)	the approximate number of days:		
b)	the approximate duration on each day:		
c)	the reason that the performance must take the form of night work:		
10)	 a)  The sums to be earned by the 
      child in taking part in the 
      performance or activity:		
b)	The name, address and  description of the person to whom or to which the sums are to be paid (if not to the child in question):		
		
11)	Where a licence is requested in respect of a performance, the proposed arrangements for any rehearsals prior to the first performance for which a licence is requested. For each rehearsal please state the date, the place, and the approximate time and duration: 	

	
		
12)	The days or half days on which leave of absence from school is requested to enable the child to take part in the performance, rehearsals or activity:		
	
13)	Proposed arrangements (if any) for the education of the child during the period for which the licence is requested stating - 	
a)	Where the education is to be provided by a school, name and address of the school:		
b)	Where the education is to be provided other than by a school:
i.	name, address and qualification of the proposed teacher;	 	
ii.	the place where the child will be taught;		
iii.	the proposed course of study;		
iv.	the number of other children to be taught at the same time by the same teacher and the sex and age of each child;		
v.	whether the child is to receive the  amount of education in accordance with regulation 13(3)(e) of the Children (Performances and Activities) (England) Regulations 2014		

14)	The name and address of the proposed chaperone, or the name and address of the parent or teacher who will have care of the child:		
		
15)	The name of the local authority or (in Scotland) the education authority (if any) which has previously approved the appointment of the chaperone: 		
		
16)	The number of children to be in the charge of the chaperone during the time when the chaperone will be in charge of the child and the sex and age of each child: 		
		
17)	The address of any accommodation where the child will live, if different from the place where the child would ordinarily live, the number of other children and details of the chaperone (if any) who will live in the same accommodation: 		
		
18)	a) Approximate length of time  
   which the child will spend 
   travelling to and from the place 
   of performance, rehearsal or 
   activity each day:		
b)	Arrangements (if any) for transport there:		
c)	Arrangements (if any) for transport back:		
		
19)	The name of any other local authority, or in Scotland, any education authority to which an application has been made for another child to take part in performances or activities to which the application relates (if not known at the time of application, to be provided when known):		
Note: this will help the relevant local authorities to take a consistent approach. 
Part 2: Information to be provided by the applicant in relation to the child
Note: the applicant will usually need to obtain this information from the child’s parent, and a parent of the child needs to sign the completed form, but the form should be submitted by the applicant (unless the parent is also responsible for organising the activity or production). See regulation 4 of the Children (Performances and Activities) (England) Regulations 2014.   
 
1)	Child’s name:		

2)	Child’s home address:

		
3)	Child’s date of birth:		

4)	Name and address of the school the child currently attends: 
OR
If the child is not attending school, the name and address of the child’s private teacher:		
	
5)	Details of each licence in relation to the child granted during the twelve months preceding the date of the application by any local authority, or in Scotland, any education authority, other than the licensing authority to which this application is made, stating -     	
a)	The name of the authority:
		
b)	The date the licence was granted:
		
c)	The dates and nature of performances or activities:

		

6)	Details of each application in relation to the child for a licence refused by any other authority in the last 12 months, other than the licensing authority to which this application is made, stating - 	
a)	The name of the local authority or education authority:		
b)	The reasons (if known) for the refusal to grant a licence:		

7)	Details of any performances for which a licence was not required in which the child took part during the previous 12 months, stating - 	
a)	The date of the performance:
		
b)	The number of days of performance:		
c)	The title of the performance:
		
d)	The name and address of the person responsible for the production:		

8)	Dates (if any) on which the child has been absent from school during the twelve months preceding the date of the application by reason of taking part in a performance or activity: 		

9)	Amount of any monies earned by the child during the last twelve months, stating whether the monies earned were in respect of performances or activities for which a licence was granted or a performance for which a licence was not required:	

Medical declaration to be completed by child’s parent
Does your child have:
(answer yes or no)	If yes please provide details including any treatment or medication: 	
Asthma		
Any allergies		
Any skin conditions		
Hearing impairment		
Visual impairment		
Any learning disability		
Any physical disability		
Any medical conditions?		
Taking any regular medication(s)?		
Been to see or had a referral to a hospital consultant in the last 6 months?		
I confirm that I have parental responsibility for this child.
	Signature of parent:

	
	Print Name:	
Postal Address (if different from child)

Parents Email Address

Parents Telephone No.		
Date:
		
I certify that to the best of my knowledge the details in this application are correct. I hereby apply for a licence under section 37 of the Children and Young Persons Act 1963:
Signature of applicant:
(To be signed by person 
named on page 1)		
Date: 

I attach the following:
(a)	A copy of the child’s birth certificate (scanned copies are acceptable – please do not send original hard copies); 
(b)	Two identical prints (un-mounted) of a photograph of the child taken during the last 6 months or an electronic likeness (e.g. a jpeg file);
(c)	A copy of the contract, draft contract or other documents (where they exist) containing details of the agreement regulating the child’s participation in the performance or activity to which this application relates.  

Notes: 
1)	Electronic versions of this form and electronic documentation are acceptable, including signatures. 
2)	You should ensure that the parent/guardian and the chaperone are given a copy of the whole completed form, which you submit to the local authority.
3)	Any person who fails to observe any condition subject to which a licence is granted or knowingly or recklessly makes any false statement in or in connection with an application for a licence is liable to a fine not exceeding £1000 (level 3 on the standard scale) or imprisonment for a term not exceeding three months or both (section 40 of the Children and Young Persons Act 1963).

Please return to:
Solihull MBC
Inclusion Service
Elmwood Place
37 Burtons Way
Birmingham
B36 0UG

Telephone 0121 704 6663

Email -  inclusion@solihull.gov.uk