Please help A+MT by completing this form. The information you give us is strictly confidential. It will enable us to keep you informed about future activities and it will help us to develop a wide-ranging programme to meet the needs of all our users, and to produce statistics about participation in our work.

Personal Details
Name
Organisation / Business Name (If applicable)
Address
Town
County
Postcode
Is this your home or work address?	Home Work Both
Telephone
Mobile
Email	Please give clear email details. Unless you specify you wish to receive material by post, we will email information to you.
Date of Birth	-- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / --- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / ---- 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Gender	Male Female
What is your arts practice? (tick as many as are appropriate)
Visual Arts Crafts Performing Arts Digital / Multimedia Arts Writing Music Arts Administration / Management Other / None of these
Please give more details about your arts practice, or your job title
Employment History
Do you work in the above field as:
Full-Time Professional Part-Time Professional Amateur Other, please specify:
If this is your professional occupation, how long have you worked in this field?
Less than three years Three to ten years Over ten years
Please state your main occupation if it is not as above?
Ethnic Group (Please tick the one you feel is most appropriate)
White - British White - Irish White - Other Black / Black British - African Black / Black British - Caribbean Black / Black British - Other Mixed - White / Black Caribbean Mixed - White / Black African Asian / Asian British - Indian Asian / Asian British - Pakistani Asian / Asian British - Bangladeshi Mixed - White / Asian Mixed - Other Chinese Other Prefer not to say
Do you consider yourself to be disabled?
Yes No
Do you have any access or support needs? (Please specify)
Database Information
The data controller is Arts+Media Training. The information you provide will be held on our database which will be used to send you details of Arts+Media Training’s programme only. Please state if you are happy for your data to be used in this way.
Yes No
Occasionally other arts agencies (e.g. funding bodies, training organisations) ask us to share your details in order to contact you with information about their services. Please indicate if you would be happy for use to pass on your details.
Yes No
Where did you learn about Arts+Media Training
Recommended by colleague Email directly from Arts+Media Training Forwarded email by person or organisation Arts+Media Training brochure Other publication / brochure Internet search Other
How would you like to recieve information about Arts+Media Training’s programme? (Tick both if appropriate)
Email (Email newsletter sent no more than once a month, with occasional one-off emails)
Post (via printed brochure three times a year, with occasional one-off mailings)
Any other comments