Step Up Parental Consent Form 2021

Step Up YDP - Cabra For Youth Parent/Guardian Consent Form

For your young person to participate in the Youth Diversion Project this form must be fully completed & returned to: [YJW/YDP contact information]
To Be Completed by Parent/Guardian
Young Person's Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date

DayMonthYear
Current Age
Address of Young Person*

Street Address

Street Address Line 2

City

Eircode / Postcode
Young Person's Phone Number
Please enter a valid phone number.Format: 000 000 0000.
Name of School / Training Centre
Highest Level of Education attained to date *
Student ( not working or looking for work )Unemployed seeking employmentOut of work and not seeking employment and not in Education / Training

Emergency Contact Details
Parent/Guardian Name (1)*

First NameLast Name
YesNo
Parent / Guardian's Address (1)*

Street Address

Street Address Line 2

City

Eircode / Postcode
Mobile Number - Parent/Guardian (1)*
Please enter a valid phone number.Format: 000 000 0000.
Parent/Guardian Name (2)

First NameLast Name
YesNo
Parent/Guardian's Address (2)

Street Address

Street Address Line 2

City

Eircode / Postcode
Mobile Number - Parent/Guardian (2)
Please enter a valid phone number.Format: 000 000 0000.
Alternative Emergency Contact
Alternative Contact Name :*

First NameLast Name
Alternative Contact Mobile Number*
Please enter a valid phone number.Format: 000 000 0000.
Alternative Emergency Contact's Address

Street Address

Street Address Line 2

City

Eircode / Postcode
Relationship to Young Person :*
eg , Grandparent , Family Friend etc

Screening Consent
Your son/daughter has been referred to Step Up (Cabra for youth Clg) by First Name Last Name To assess if they are suitable for the project we will look at the needs that the project may be able to address for them. Step Up works with other agencies such as the Gardaí, schools etc. to provide the best possible service to young people and their families. This may involve sharing information with them. If Step Up is not in a position to meet your son/daughter's needs we may recommend a more suitable support for them.
Young Person's Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address of Young person*

Street Address

Street Address Line 2

City

Eircode / Postcode
YesNo
Parent / Guardian's Address*

Street Address

Street Address Line 2

City

Eircode / Postcode
Mobile Number of Parent / Guardian
Please enter a valid phone number.Format: 000 000 0000.
Consent

I understand that my son/daughters needs will be assessed to help decide if the GYDP could be of benefit to them. I understand that the project works with other agencies to ensure that my young person’s needs are met in the best possible way. This may involve sharing relevant information. I agree to this. I also understand that this information will be kept in accordance with the Data Protection Act 1998 &2003. More information available at www.iyjs.ie.
Full Name of Parent / Guardian*
Relationship to Young Person*
Parent / Guardian Signature *

Clear
Date*

DayMonthYear
Young person Consent

Cabra For Youth is committed to providing a service to all suitable young people irrespective of their gender, ethnic background, culture, sexuality, ability or religion. Our activities are based upon the principle of respect. Bullying in any form will not be tolerated. As a participant in the project, I agree to follow this equality statement. I also understand and agree to the project using what they know about me to plan activities and programmes to meet my needs in the best possible way .
Young Person's Signature*

Clear
Date*

DayMonthYear
This project is co-funded by the Government of Ireland and the European Union

For more information see www.eufunds.ie
File Upload

Cancelof
Should be Empty:

Rows	Yes	No
Engage with the Youth Diversion Project
Take part in programmes/activities in the Project (incl 1:1’s, group sessions etc.)
Be taken to A&E/a doctor in case of medical emergency
Visit and leave the Project during drop-in times at their own discretion
Participate/Attend Event nights, Overnights and/or Day trips with the Project
Be included in any publicity photographs for the Project & the European Social Fund Plus ( ESF+)
My child can swim 25m (1 pool length) or more
I consent to the use of images all social media platforms including via phone and text messaging
I consent to my child / Young person to engaging with the youth service online , this may including online gaming or video calls e.g. zoom calls
Be contacted by staff in Cabra For Youth by any means, eg , phone , text , Social media but not exclusive to

Step Up YDP - Cabra For Youth Parent/Guardian Consent Form

To Be Completed by Parent/Guardian

Other Information

Emergency Contact Details

Alternative Emergency Contact

Medical Information

Consent

Screening Consent

Consent

Young person Consent

This project is co-funded by the Government of Ireland and the European Union