Youth Consent Form

Full name of child/young person *
Home Address: *
Postcode *
Home Phone *
Date of birth *
With whom does the child/young person live? *
Relationship to child/young person *
Who has parental responsibility for the child/young person? (please give name/s, address and mobile number) *
2nd Contact name, address and mobile number if different to the question above : *
In case of us not being able to contact the above, please give an additional emergency contact name: *
Home number for additional contact *
Mobile number for additional contact *
Relationship to child/young person *
Child’s/young person’s registered GP *
GP Address *
GP Phone Number *
Whilst in our care it is important we know whether your child: Suffers from any allergies *
Is on any medication *
Has any health conditions that we should know about *
Has any special educational needs that we should know about *
On occasions we may use photos and videos for the purposes of recording our events. Please tick the appropriate box(es) to let us know whether or not you give consent for your child’s image to be used for any of the following official publications *	Printed Publications theBarn Website Church Social Media Pages
I understand that this form, and therefore information given, will be held securely on the premises where the group meets and will be made available to leaders as appropriate. I give permission for my son/daughter to take part in the normal activities of *
In an emergency and/or if I cannot be contacted, I am willing for my child to receive necessary hospital or dental treatment including an anaesthetic *
Name (only the parent or adult with parental responsibility may fill this box in) *
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