Personal Information File

For legal and insurance purposes we need to keep a record of your personal information. This information includes your name, contact details and the person to contact in case of emergency. All personal information is treated as confidential and in line with Data Protection requirements. In order to do this, we need your permission.

CONSENT: BY submitting the following information I give my written consent for Black Country Radio to hold personal information about me.

First Name

Last Name

On Air Name

Date of Birth

House Number / Name

Street Name

City / Town

Post Code

Mobile Phone

Home Phone

Email Address

Please state below who we should contact in an emergency.

First Name

Last Name

House Number / Name

Street Name

City / Town

Postal Code

Mobile Phone

Home Phone

Relationship to you

Do you have any medical or physical problems that you feel Black Country Radio should be aware of?
If yes - please enter any medical concerns or physical issues that may affect your volunteering duties in the box below.

Medical Advice

Yes No

Medical Advice

Date

This can be left alone:

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Personal Information File

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