Annual Registration Form 2023/24

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By continuing to fill out this form, you are agreeing that you are the responsible adult for this young person (i.e. their parent or guardian). Please note, we may contact you upon submission of the form to confirm that it has been completed by the parent or guardian of the young person.* This field is required.(If you are a young person reading this, please ask your parent or guardian to fill out this form).
I confirm that I am the young person's parent or guardian
2
Young Person's Information* This field is required.
First name
Last Name
Date of Birth (00/00/0000)
School & Year Group (or equivalent)
Address
3
How will the young person normally get home?* This field is required.
Parent/Guardian will collect
They will make their own way home
Other
4
LEAVING PROGRAMME BEFORE IT ENDS - I agree that my young person can leave programmes when they choose to and that when they do Crumlin Youth For Christ will not be responsible for them once they have left the premises. This DOES NOT apply to any programmes for Primary School aged young people.* This field is required.(If you are a young person reading this, please ask your parent or guardian to fill out this form).
I agree
5
Young Person's GP Details* This field is required.
Name of GP
Contact number of GP
Address of GP
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Young Person's Health and Care NumberPlease do your best to provide this. Your GP will be able to provide you with it if you do not know it. You can also request a new medical card (https://hscbusiness.hscni.net/services/2507.htm)
Health and Care Number
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Details of any Medical ConditionsPlease provide information on any medical conditions your young person has, including directions on how we can best look after your young person while they are in our care.
Details of any known conditions or allergies etc. (i.e. asthma, diabetes, epilepsy, anxiety) and any medication your young person takes.
Any specific needs, requirements or directions for looking after your young person that leaders should know.
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Parent / Guardian's Information* This field is required.
First name
Last Name
Relationship to Young Person
Contact Number(s)
Email Address
9
Do you give us permission to contact you via text/WhatsApp or email with occasional updates about our programmes?* This field is required.
Text
Email
No thanks, I don't want to know.
10
Secondary Contact Information* This field is required.
First name
Last Name
Relationship to Young Person
Contact Number(s)
11
MEDICAL: In the event of illness or accident, having parental responsibility for the above-named young person, I give permission for first aid to be administered where considered necessary by a first aider, and emergency hospital treatment to be administered in the case where I and the second contact cannot be contacted and where this is advised by a medical professional.* This field is required.If you tick no, we will follow this up with you.
Yes, I give consent
No, I don't give consent
12
PHOTOS, VIDES & AUDIO: Photos, videos and audio may be taken of my young person during programmes and events, which may be used internally and externally on Crumlin Youth For Christ and Youth For Christ Northern Ireland websites, social media and other online or offline funding and publicity material.* This field is required.
Yes, I give consent
No, I don't give consent
13
CONTACTING YOUR YOUNG PERSON: Staff may contact my young person as part of their youth work duties (providing information, resources or checking in etc.). This will be carried out using the Crumlin Youth For Christ mobile or social media accounts. Please tick all that apply.
Text (Year 8+)
Facebook (13+)
Instagram (13+)
WhatsApp (16+)
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Young Person's mobile number.Fill this out if you have given us permission to contact your young person by text or WhatsApp.
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ONLINE ENGAGEMENT: In recent times youth workers have had to engage online via Zoom (specific rules regarding online engagement will be distributed where necessary). Do you consent to your young person taking part in online programmes where necessary?* This field is required.
Yes, I consent
No, I don't consent
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I confirm that the details on this form are correct to the best of my knowledge and that I will inform staff immediately of any changes to my young person’s health, medication or needs, as well as any changes to my address or contact numbers given above.* This field is required.
Yes
No
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Signature* This field is required.Please use your finger or mouse to sign.
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Print Name* This field is required.
Should be Empty: