Family Support Step Up

Family Support - Engagement Consent Form Step Up

These forms must be fullycompleted by persons who will engage in Family Support within the YDP & returned to; [Family Support Worker/ YDP contact information]
To Be Completed by Parent/Guardian
Parent / Guardian Name

First NameLast Name
Name of Young Person's engaged / referred to YDP *

First NameLast Name
Relationship to Young Person
Address of Parent / Guardian*

Street Address

Street Address Line 2

City

Eircode / Postcode
Parent / Guardian Mobile Number
Please enter a valid phone number.

Step Up is part of the Youth Diversion Programme. The Youth Diversion Programme is co-financed by the Department of Justice and the European Social Fund Plus (ESF+) as part of the Operational Programme “Employment, Inclusion, Skills and Training (EIST)”. The data provided by you on this form will be collected and processed by Step Up in connection with your participation in the Youth Diversion Programme.

Provision of the information sought below is not mandatory, and participants retain the right to choose not to disclose this information. Where participants exercise this right “Not Disclosed” should be ticked

Click Here to view the leaflet

Consent

This Youth Diversion Project is committed to providing a service to all suitable persons 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.
Parent / Guardian 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

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Additional Family member ( Over 18 )
Under 18 Additional Family Member (1)

First NameLast Name
Relation to Young Person
Address same as Above?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Step Up is part of the Youth Diversion Programme. The Youth Diversion Programme is co-financed by the Department of Justice and the European Social Fund Plus (ESF+) as part of the Operational Programme “Employment, Inclusion, Skills and Training (EIST)”. The data provided by you on this form will be collected and processed by Step Up in connection with your participation in the Youth Diversion Programme.

Provision of the information sought below is not mandatory, and participants retain the right to choose not to disclose this information. Where participants exercise this right “Not Disclosed” should be ticked

Click Here to view the leaflet
Medical Information Additional Person
Do you have any medical conditions that may impact your involvement in Family Support in the Youth Diversion Project?*

YesNo
Please specify additional information
Do you have any other condition that staff should be aware of, which may require individual planning and consideration, including conditions affecting learning or social interaction?*

YesNo
Please specify additional Information
I understand that the Project works with other agencies; An Garda Síochána, Tusla and schools/education centres, social workers and counsellors to ensure that the family’s needs are met in the best way possible. This may involve sharing relevant information with them. I understand that the family’s needs will be assessed to help create a plan for them. I also understand that this information may be used to compile statistical data to be transmitted to other relevant organisations; Department of Justice, Department of Further and Higher Education, Research, Innovation and Science, University of Limerick, European Union agencies and other relevant bodies which the Department of Justice may decide for the purpose of conducting evaluations and research. I understand that my pseudonymised data will be stored on behalf of the Department of Justice. I understand that this information will be kept in accordance with the Data Protection Act 1988, 2003 & 2018. I agree to this : :

YesNo

Consent Permission*

	Yes	No
Engage with the Family Support YDP
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
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+)
I can Swim 25 meters or more
I consent to the use of images all social media platforms including via phone and text messaging
Be contacted by staff in Cabra For Youth by any means, eg , phone , text , Social media but not exclusive to

The youth service does not tolerate the involvement of alcohol, drugs and/or sexual activity whilst engaging in activities with the service. If found to be engaging in any of the above, the parent/guardian will be to leave the activity. I agree to the above policy'

YesNo
By signing this I acknowledge the current risks associated with Covid-19 and that Cabra for Youth will endeavor to minimize these risks and implement all HSE guidelines.

I will make sure that my child/young person will adhere to social distancing and hand sanitisation guidelines and wear a mask where appropriate while engaging with Cabra for Youth Clg Yes No*
Consent

This Youth Diversion Project is committed to providing a service to all suitable persons 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.
Additional Family Member Signature

Clear
Date

DayMonthYear

Under 18's Additional Consent (1)
Additional Under 18 Family Member (1)

First NameLast Name
Relation to Young Person
Address same as Above?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Step Up is part of the Youth Diversion Programme. The Youth Diversion Programme is co-financed by the Department of Justice and the European Social Fund Plus (ESF+) as part of the Operational Programme “Employment, Inclusion, Skills and Training (EIST)”. The data provided by you on this form will be collected and processed by Step Up in connection with your participation in the Youth Diversion Programme.

Provision of the information sought below is not mandatory, and participants retain the right to choose not to disclose this information. Where participants exercise this right “Not Disclosed” should be ticked

Click Here to view the leaflet
Medical Information Additional Person
Do you have any medical conditions that may impact your involvement in Family Support in the Youth Diversion Project?*

YesNo
Please specify additional information
Do you have any other condition that staff should be aware of, which may require individual planning and consideration, including conditions affecting learning or social interaction?*

YesNo
Please specify additional Information
I understand that the Project works with other agencies; An Garda Síochána, Tusla and schools/education centres, social workers and counsellors to ensure that the family’s needs are met in the best way possible. This may involve sharing relevant information with them. I understand that the family’s needs will be assessed to help create a plan for them. I also understand that this information may be used to compile statistical data to be transmitted to other relevant organisations; Department of Justice, Department of Further and Higher Education, Research, Innovation and Science, University of Limerick, European Union agencies and other relevant bodies which the Department of Justice may decide for the purpose of conducting evaluations and research. I understand that my pseudonymised data will be stored on behalf of the Department of Justice. I understand that this information will be kept in accordance with the Data Protection Act 1988, 2003 & 2018. I agree to this : :

YesNo

Consent Permission*

	Yes	No
Engage with the Family Support YDP
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
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+)
I can Swim 25 meters or more
I consent to the use of images all social media platforms including via phone and text messaging
Be contacted by staff in Cabra For Youth by any means, eg , phone , text , Social media but not exclusive to

The youth service does not tolerate the involvement of alcohol, drugs and/or sexual activity whilst engaging in activities with the service. If found to be engaging in any of the above, the parent/guardian will be to leave the activity. I agree to the above policy'

YesNo
By signing this I acknowledge the current risks associated with Covid-19 and that Cabra for Youth will endeavor to minimize these risks and implement all HSE guidelines.

I will make sure that my child/young person will adhere to social distancing and hand sanitisation guidelines and wear a mask where appropriate while engaging with Cabra for Youth Clg Yes No*
Consent

This Youth Diversion Project is committed to providing a service to all suitable persons 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.
Parent / Guardian Sign here

Clear
Date

DayMonthYear

Under 18's Additional Consent (2)
Under 18 Additional Family Member Name (2)

First NameLast Name
Relation to Young Person
Address same as Above?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Step Up is part of the Youth Diversion Programme. The Youth Diversion Programme is co-financed by the Department of Justice and the European Social Fund Plus (ESF+) as part of the Operational Programme “Employment, Inclusion, Skills and Training (EIST)”. The data provided by you on this form will be collected and processed by Step Up in connection with your participation in the Youth Diversion Programme.

Provision of the information sought below is not mandatory, and participants retain the right to choose not to disclose this information. Where participants exercise this right “Not Disclosed” should be ticked

Click Here to view the leaflet
Medical Information Additional Person
Do you have any medical conditions that may impact your involvement in Family Support in the Youth Diversion Project?*

YesNo
Please specify additional information
Do you have any other condition that staff should be aware of, which may require individual planning and consideration, including conditions affecting learning or social interaction?*

YesNo
Please specify additional Information
I understand that the Project works with other agencies; An Garda Síochána, Tusla and schools/education centres, social workers and counsellors to ensure that the family’s needs are met in the best way possible. This may involve sharing relevant information with them. I understand that the family’s needs will be assessed to help create a plan for them. I also understand that this information may be used to compile statistical data to be transmitted to other relevant organisations; Department of Justice, Department of Further and Higher Education, Research, Innovation and Science, University of Limerick, European Union agencies and other relevant bodies which the Department of Justice may decide for the purpose of conducting evaluations and research. I understand that my pseudonymised data will be stored on behalf of the Department of Justice. I understand that this information will be kept in accordance with the Data Protection Act 1988, 2003 & 2018. I agree to this : :

YesNo

Consent Permission*

	Yes	No
Engage with the Family Support YDP
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
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+)
I can Swim 25 meters or more
I consent to the use of images all social media platforms including via phone and text messaging
Be contacted by staff in Cabra For Youth by any means, eg , phone , text , Social media but not exclusive to

The youth service does not tolerate the involvement of alcohol, drugs and/or sexual activity whilst engaging in activities with the service. If found to be engaging in any of the above, the parent/guardian will be to leave the activity. I agree to the above policy'

YesNo
By signing this I acknowledge the current risks associated with Covid-19 and that Cabra for Youth will endeavor to minimize these risks and implement all HSE guidelines.

I will make sure that my child/young person will adhere to social distancing and hand sanitisation guidelines and wear a mask where appropriate while engaging with Cabra for Youth Clg Yes No*
Consent

This Youth Diversion Project is committed to providing a service to all suitable persons 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.
Parent / Guardian Sign here

Clear
Date

DayMonthYear
Should be Empty:

Family Support - Engagement Consent Form Step Up

To Be Completed by Parent/Guardian

Medical Information

Consent

Consent

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

Medical Information Additional Person

Consent

Medical Information Additional Person

Consent

Medical Information Additional Person

Consent