Isle of Wight Council

Medina Theatre - APPLICATION FORM

	Fairlee Road Newport Isle of Wight PO30 2DX Tel : 01983-527020 ~ Fax : 01983-822821
	Application form for hire of Medina theatre - This form must be taken to the theatre box office to be completed along with the Statement of Cost for Private Hire of Medina Theate form. NOTE: Completion of both forms does not confirm booking.

Organisation

*	Name of organisation
	Registered charity no. (if applicable)

Contact Name

*	Forename
	Middle name/Initials
*	Surname

Address

*	Building/house name/number
*	Street address
*	Town name
	County
*	Postcode
	Tel number (include area code)
	Mobile number
	Email address
	Fax

The Event

*	Date(s) required
*	Event details
	Event category	A    B    C     D
*	Admission charge	Yes No
*	Will tickets be issued?	Yes No
	Insurance category	Non-commercial hire      Commercial hire
	Indemnity returned	Yes No
*	Date booking opens
*	Concessionary rates?	Yes No
	*If 'yes', please give details
*	Tickets obtainable from	Box Office    Other*
	*If 'other', please specify

Declaration

I hereby agree to observe and perform all the conditions of hire of Medina Theatre and to pay all necessary charges in accordance with the scale of charges for the time being in force. A copy of the said scale of charges (statement of cost for private hire of Medina Theatre) has also been completed in support of this form and the hirer is deemed to have full knowledge and notice thereof.

I include a remittance of

� in full/part payment of the hire fee.

In the event of any cancellation by the hirer within four weeks of the event, the full hire fee will be retained.

This hiring is on behalf of

whose authority I have to bind them by signing this application on their behalf. On signing, I have read and agree to the terms and conditions for hiring Medina Theatre

Signed............................................................... Name................................................................ Date..................................................................

Method of payment

Cheques should be made payable to Medina Theatre. This completed application should be forwarded to Medina Theatre at the address shown above, together with your payment and statement of costs form.

	For office use only
	Hire charge ........................................................ Letting approved ................................................ Date .................................................................

	Data Protection Act 1998
	This application may be monitored by the Isle of Wight Council for regulatory, quality control or crime detection purposes. Information from this application will be processed in accordance with the Data Protection Act 1998 for the purpose of processing your particular enquiry/request. The Isle of Wight Council ("the Council") is the data controller. By completing this form you consent to the Council contacting you by email or nominated contact method in relation to your enquiry/request. The information contained in this application may, in exceptional circumstances, be subject to disclosure to third parties under either the Data Protection Act 1998 or the Freedom of Information Act 2000 to the extent the law allows and in accordance with the Isle of Wight Council's Access to Information Policy . Disclosure will only be made where in all the circumstances it would be fair to do so and in the public interest. Please note that the Council may process your information in the absence of consent for the purpose of crime prevention or detection so far as is in accordance with the law. Sometimes we may use your information to keep you informed about services, goods or relevant issues that we believe may be of interest to you. If you wish to receive this information for these purposes please tick this box To improve the quality of other services that we provide to you the Council wishes to hold your non-sensitive personal information on a secure central database. This will enable all Council services to use this information when they are providing a service to/for you. If you wish your non-sensitive personal information to be held by the Council please tick this box

Date printed: 08/03/2013