Buxton Summer Ball - Parental Consent Form

Buxton Summer Ball 2026

Parental Permission to attend the above named event. This form is to be completed and submitted by the parent/guardian of the Derbyshire YFC members aged 16-17. It gives consent for the member to attend and states the details of the individual who is a DFYFC member & 18+*, who has responsibility for the supervision of them and is in a position of responsibility and authority for them to sign, on your behalf, any papers needed by the medical authorities in case of emergency hospital treatment. *Supervising adult MUST arrive with under 18 year old to gain entry!
DATE: Friday 3rd July 2026

VENUE: Kenslow Farm, Middleton By Youlegrave, DE45 1LY

TIME: 8.30pm - 1.30am

All under 18 members must show proof of their current DERBYSHIRE membership on the door.
MEMBER DETAILS

(This section should be completed, signed by parent/guardian and submitted to the event organiser)
Member Name

Member First NameMember Surname
Date of Birth

DayMonthYear
Date of Birth
Address

Address Line 1

Address Line 2

Town / CityCounty

Post Code
NFYFC Membership Number
Note all those under 18s attending must be a current Derbyshire YFC member for the year 2025/26
MEDICAL HISTORY
Has the named participant ever suffered from any of the following conditions: Diabetes, Asthma, bad period pains, Migraine, Epilepsy or any other illness?
If Yes, give details;
Is the named participant allergic to anything (e.g. antibiotics, penicillin, Elastoplast's, aspirin or any such medicines, any particular food, etc.)?
If Yes, give details;
Is the named participant receiving any medical treatment or on any prescribed medication?
If Yes, give details;
Does the participant have any disabilities and/or behavioural difficulties?
If Yes, give details;
Details of any medication to be taken, include frequency and any relevant side effects?
Does the participant have any other special needs? (dietary, wheelchair access, etc.)?
Any other relevant information
EMERGENCY CONTACTS

Please provide details of 2 in case of emergency contacts - available to contact for the duration of the event detailed above.
Name1 - Parent/Guardian

Parent/Guardian First NameParent/Guardian Last Name
Home Phone Number

Area CodePhone Number
Mobile Phone Number
Please enter a valid phone number.Format: 00000 000000.
Name2 - Parent/Guardian

2nd Parent/Guardian First Name2nd Parent/Guardian Surname
Home Phone Number

Area CodePhone Number
Mobile Phone Number
Please enter a valid phone number.Format: 00000 000000.
SUPERVISER AT EVENT

Parent / Guardian to provide details of the adult nominated to supervise the under 18 member named above.
Name of person to supervise under 18 years old member:

Supervisor - First NameSupervisor - Surname
Membership Number of the Over 18 DFYFC Member :
Club Federation:
Mobile Telephone Number:
Please enter a valid phone number.Format: 00000 000000.
DECLARATION
The medical information provided on this form is correct as far as I know and in the event of illness or accident requiring hospital treatment, I give consent for the named supervisor or equivalent to sign on my behalf any written form of consent required by the hospital authorities, if the delay to obtain my own signature is considered inadvisable by the doctor/surgeon concerned.

I understand that the insurance policy is available to me via the county office or NFYFC and understand the extent and limitations of the insurance cover provided. I understand that while the adults in charge of the event will take all reasonable care of the young people, they cannot necessarily be held responsible for any loss, damage or injury suffered arising during or as a result of the activity.
Parent / Guardian Signature
Parent / Guardian Name completing this form

Person Completing Form (First Name)Person Completing Form (Surname)
Address

Address Line 1

Address Line 2

Town / CityCounty

Post Code
Parent / Guardian Email
example@example.com
Date form completed

DayMonthYear
Date
Should be Empty:

Buxton Summer Ball 2026

MEMBER DETAILS

MEDICAL HISTORY

EMERGENCY CONTACTS

SUPERVISER AT EVENT

DECLARATION