CHW 18 PARENTAL CONSENT FORM

CHW: Parental Consent Form

ALL UNDER 18'S MUST HAVE PARENTAL CONSENT
CHILD'S FULL NAME: *

First Name Last Name
DOB: *

Day Month Year
GENDER: *

Male Female
ACCOMMODATION DURING CHW: *

CASTLE CAMPSITE OFF SITE
NAME OF PARENT | GUARDIAN: *

First Name Last Name
EMERGENCY INFORMATION:
1ST Emergency Contact: *

First Name Last Name
MOBILE:

Area Code Phone Number
2ND Emergency Contact: *

First Name Last Name
MOBILE:

Area Code Phone Number
GP INFORMATION:
DOCTOR'S NAME: *

First Name Last Name
PHONE NO: *

Area Code Phone Number
GROUP INFORMATION:
AGE GROUP: *

CRECHE (UNDER 3 YO) NANOS (3 YO) MINIS (4-5 YO) MICROS (6-8 YO) MEGAS (9-11 YO) SECTOR 1 (12-14 YO) SECTOR 4 (15+)
If your child is in the MEGAS, please indicate if you give permission for them to walk back to their accommodation rather than be collected.

PLEASE NOTE: A leader will accompany children to the campsite and castle to make sure they are safe.
I GIVE PERMISSION FOR MY 'MEGA' TO WALK BACK RATHER THAN BE COLLECTED:

YES NO
FOR CHILDREN BEING COLLECTED, PLEASE LIST THE NAMES OF THOSE WHO MAY COLLECT:
I GIVE PERMISSION FOR MY CHILD TO: (Please tick) *

BE GIVEN SNACKS (We are a NUT FREE zone) GO OUTSIDE FOR ACTIVITIES BE GIVEN BASIC FIRST AID IN THE CASE OF MINOR ACCIDENT HAVE THEIR PHOTO TAKEN FOR PUBLICITY PURPOSES** NONE OF THE ABOVE ALL OF THE ABOVE
**PHOTOS: Sometimes we may use the photos to promote CHW through our website and social media platforms or other publicity. Please note that if we wish to use a photograph of an individual young person we will always seek additional permission. If you are unhappy about your child appearing in any of the photos, please speak to the age group leader so that we can make special arrangements.
PLEASE INDICATE ANY MEDICAL CONDITIONS IT IS ESSENTIAL LEADERS NEED TO BE AWARE OF:
EG: ALLERGIES | DIETARY REQUIREMENTS | MEDICATION TO BE TAKEN
DOES YOUR CHILD HAVE ANY ADDITIONAL NEEDS WHICH AGE GROUP LEADERS NEED TO KNOW ABOUT TO HELP THE CHILD ENGAGE AS FULLY AS THEY CAN IN PROGRAMME? *

YES NO
IF YOU ANSWERED YES TO THE SPECIAL NEEDS QUESTION ABOVE, PLEASE GIVE DETAILS BELOW:
BEHAVIOURAL DISORDERS | EDUCATIONAL DISORDERS | DOWN SYNDROME
IMPORTANT: PLEASE READ

I will inform the leaders of any important changes to my child's health, medication or needs and also of any change to our address or to any of the phone numbers given above.

In the event of illness or accident, having parental responsibility for the above named child, I give permission for First Aid to be administered where considered necessary by a trained First Aider, if available, or medical treatment to be administered by a suitably qualified medical practitioner.

If I cannot be contacted and my child should require emergency hospital treatment, I authorise an adult leader to sign on my behalf any written form of consent required by the hospital. However, I understand that every effort will be made to contact me as soon as possible.
ELECTRONIC SIGNATURE:

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
PARENT NAME: *
DATE: *

Day Month Year
Date
Should be Empty:

CHW: Parental Consent Form

EMERGENCY INFORMATION: