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 *

Did you mean @?

Last Name *

Did you mean @?

On Air Name

Did you mean @?

Date of Birth *

Day

Month

Year

House Number / Name *

Did you mean @?

Street Name *

Did you mean @?

City / Town *

Did you mean @?

Post Code *

Did you mean @?

Mobile Phone *

Did you mean @?

Home Phone

Did you mean @?

Email Address *

Did you mean @?

Please state below who we should contact in an emergency.

First Name *

Did you mean @?

Last Name *

Did you mean @?

House Number / Name *

Did you mean @?

Street Name *

Did you mean @?

City / Town *

Did you mean @?

Postal Code *

Did you mean @?

Mobile Phone *

Did you mean @?

Home Phone

Did you mean @?

Relationship to you *

Did you mean @?

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. This allows us to put in any reasonable support measures for you.

Medical Advice *

Yes

Medical Advice

The station has a closed volunteer Facebook group, which is used as a communication method. If you are on Facebook we ask that you join, however we understand that not everyone is active or chooses to be in Facebook.

Do you agree to join the group?

Yes

Date *

This can be left alone: