Youth Group Parental Consent Form

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1. What is the child’s full name? *

2. What is the child’s date of birth? (DD/MM/YY) *

3. Who is the child´s parent or guardian? *

4. What is the child´s parent or guardian relationship to the child? *

Father
Mother
Aunt
Uncle
Grandmother
Grandfather
other

5. What is the home address? *

6. What is the postcode? *

7. What is the home phone number?

8. What is the mobile phone number? *

Does full treatment

9. What is the email address? *

10. Does the child have any allergies or special needs that we should be aware of(If yes, please specify)? *

11. Could you give us more detail about any allergies or special needs of your child that we should be aware of? *

12. What is the name of the child’s doctor?

13. In case of an emergency, who should we contact? Please, write down the full name *

14. What is the phone number of the emergency contact person? *

15. I am happy for my child to walk home on their own *

Yes
No

16. Please provide any additional information about your child that we should be aware of. *

The child named above is in good health and I consider him/her capable of the activities taking place. I agree to him/her taking part in youth activities. In the event of an accident, I consent to any necessary medical treatment which might include the use of paracetamol sachets or sticking plasters. In an emergency I consent to treatment by medical health professionals, if considered necessary. *

I agree
I disagree

I also give permission for photos/video for local promotion to be taken. (children will not be identified by name) *

I agree
I disagree

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