YMCA DLG Youth Club Membership

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Is the service user over 16?* This field is required.
YESNO
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Name of Service user :* This field is required.
First Name
Last Name
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Date of birth* This field is required.Please add your date of birth in the format 01/02/09
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Age* This field is required.
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Does the service user have any allergies? If YES you must ensure that this has been identified in in the consents form
YESNO
6
Please tell us about any allergies. (We often make food)
Huge
Large
Normal
Small
Ok
Ok
7
Are you eligable for free school meals?
YESNO
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Service user's address:* This field is required.
Street Address
Street Address Line 2
Town
County
postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
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The Bahamas
Bahrain
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Belize
Benin
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Bhutan
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Bosnia and Herzegovina
Botswana
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Brunei
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Burkina Faso
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Cameroon
Canada
Cape Verde
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Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
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Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
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Djibouti
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Dominican Republic
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Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
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Greece
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Guinea
Guinea-Bissau
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India
Indonesia
Iran
Iraq
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Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
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Sri Lanka
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eSwatini
Sweden
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Syria
Taiwan
Tajikistan
Tanzania
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Timor-Leste
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Tonga
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Vanuatu
Vatican City
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Are you aware on how we will hold your information?* This field is required.
YesNo
10
Service user's phone number
11
Service user's email
example@example.com
12
Can we email you updates about YMCA DLG service closures / changes, services, events, promotions and activities?* This field is required.
YESNO
13
Service user's gender* This field is required. Please type in the box
14
Preferred personal pronoun An example of this could be he, she, they, xe or ze
15
Which YMCA DLG services are you likely to use?* This field is required.
YesNo
YesNo
YesNo
YesNo
Shinewater (Monday)
Langney youth club (Tuesday)
Willingdon Trees youth club (Friday)
Shinewater (Monday)
YesNo
YesNo
YesNo
YesNo
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16
Service user's ethnicity
English / Welsh / Scottish / Northern Irish / British
Irish
Gypsy or Irish Traveller
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple ethnic background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
African
Caribbean
Any other Black / African / Caribbean background
Arab
Any other ethnic group
Other
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Religion/Faith
Buddhist
Hindu
Christian
Jewish
Muslim
Sikh
Other
None
18
Do you identify as LGBTQU+?
YESNO
19
Please take a head shot photo (click next if your device has no camera)
20
Please upload a head shot photo (Skip if you completed the previous)This is needed to ensure we can better safeguard all young people at our clubs.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Service users medical information:* This field is required.
Yes
No
If yes please give details:
Any specific medical conditions requiring medical treatment?
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Any specific medical condition or disability?
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Any allergies?
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Details of any dietary requirements (vegan/vegetarian):
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Is there any other medical conditions that we should know about?
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Any specific medical conditions requiring medical treatment?
Any specific medical condition or disability?
Any allergies?
Details of any dietary requirements (vegan/vegetarian):
Is there any other medical conditions that we should know about?
Yes
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No
Row 0, Column 1
If yes please give details:
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Yes
Row 1, Column 0
No
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If yes please give details:
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Yes
Row 2, Column 0
No
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If yes please give details:
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Yes
Row 3, Column 0
No
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If yes please give details:
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Yes
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No
Row 4, Column 1
If yes please give details:
Row 4, Column 2
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Photography and filming consent:* This field is required.YMCA DLG will take all steps to ensure these images are used solely for the purposes they are intended. If you become aware that these images are being used inappropriately you should inform YMCA DLG immediately. Only click yes if both the service user and parents and carers are in agreement. (My =service user)
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
I give permission for my photograph to be used within the club for display purposes
I give permission for my photograph to be used within other printed publications
I give permission for my photograph to be used on the YMCA DLG website
I give permission for videos of me to be used on the clubs website
I give permission for my photograph to be used on the club’s social media pages
I give permission for videos of me to be used on the clubs social media pages
I give permission for my photograph to be used within the club for display purposes
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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Parent / Carer /Emergency Contact Name* This field is required.
First Name
Last Name
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Parent / Carer /Emergency Contact Number* This field is required.
25
Parent / Carer /Emergency Contact Email
example@example.com
26
Can we email you updates about YMCA DLG service closures / changes, services, events, promotions and activities?* This field is required.
YESNO
27
Consent and Agreement:* This field is required.
I agree
I understand that it is the responsibility of parents/carers to collect their child/young person or arrange for them to make their own way home from the agreed meeting points.
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I accept responsibility for ensuring that my child/young person abides by the agreed procedures for their safety and the safety of the group.
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I understand that YMCA DownsLink Group cannot be held responsible for any accident or incident that may occur if a child/young person leaves the site or activity.
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I certify that I have given all the information that is relevant to the wellbeing of my child/young person.
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I understand and consent to the service user participating in an Extreme Sport that can be dangerous and you accept that the use of facilities provided and or attended are entirely at your own risk and that you will not hold YMCA DLG, Directors, or employees liable in any way whatsoever for any injuries which result from using or spectating at these facilities or for any accidents, loss or damage or death whilst on these premises save in the case of negligence.
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I understand that it is the responsibility of parents/carers to collect their child/young person or arrange for them to make their own way home from the agreed meeting points.
I accept responsibility for ensuring that my child/young person abides by the agreed procedures for their safety and the safety of the group.
I understand that YMCA DownsLink Group cannot be held responsible for any accident or incident that may occur if a child/young person leaves the site or activity.
I certify that I have given all the information that is relevant to the wellbeing of my child/young person.
I understand and consent to the service user participating in an Extreme Sport that can be dangerous and you accept that the use of facilities provided and or attended are entirely at your own risk and that you will not hold YMCA DLG, Directors, or employees liable in any way whatsoever for any injuries which result from using or spectating at these facilities or for any accidents, loss or damage or death whilst on these premises save in the case of negligence.
I agree
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I agree
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I agree
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I agree
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I agree
Row 4, Column 0
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Signature (if under 16 this must be completed by a parent/carer) * This field is required.By signing; you agree that you the parent / carer or young person (if over 16) agree to the previous sections of this form and you have read and completed all of the sections to the best of your knowledge.
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