Youth Kirk Registration Form 2022

Youth Kirk Registration Form

Chalmers Memorial Church, Port Seton
Young Person Registration
Name *

First Name Last Name
Birth Date *

Day Month Year
Current Year (2022) *
Does your young person have any additional support needs? How can we support them?
Does your young person have any medical conditions or food allergies we need to be aware of?
Parent/Guardian Details
Parent/Legal Guardian Name *

First Name Last Name
Mobile Phone Number *
Email
example@example.com
Address *

Street Address

Street Address Line 2

Town County

Post Code
Who will collect your young person?

First Name Last Name
If your young person can walk home themselves, please tick the box below *

I Agree Someone will collect
Additional Info
Emergency Contact 1 (other than parent/guardian listed above) *

First Name Last Name
Relationship
Mobile Phone Number *
Emergency Contact 2 (other than parent/guardian listed above) *

First Name Last Name
Relationship
Mobile Phone Number *
By clicking the box below, I hereby give permission for photographs and/or video in which my young person appears in to be used by the church in printed and/or electronic media, including the church's website / Facebook Page. *

I Agree I Do Not Agree
Confirm *

Within the Church & Hall On Facebook On Church website I Do Not Agree
I give permission for the above named young person to take part in all activities at Youth Kirk. In the unlikely event of illness or accident, I give permission for any necessary medical treatment to be given by the nominated first-aider. In an emergency and if I can’t be contacted, I am willing for my child to receive hospital treatment, including anaesthetic if necessary. I understand that every effort will be made to contact me as soon as possible. I understand that all due care, supervision and precautions will be taken at all times but that ultimately my son/daughter is responsible for his/her own actions and club leaders cannot necessarily be held responsible for any loss, damage or injury suffered by my child during or as a result of, the activity *

I Agree
I consent to the use by Chalmers Memorial Church of the personal information provided for Youth Kirk to store my young person’s data. The information will be used for inviting to future events. You can withdraw or change your consent at any time by contacting Sheila Bulloch / Amanda Johnston by email – kidskirk@chalmerschurch.co.uk / 07980 059 974 *

I Agree
If you or anyone in your household have Covid-19 symptoms or are self isolating I will NOT bring my child to the event *

I Agree
I agree that my child will wear a face covering unless exempt *

I Agree
Should be Empty:

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Youth Kirk Registration Form

Young Person Registration

Parent/Guardian Details