Youth Mix November 2025

Youth Mix Booking & Consent Form
NOW ONLY ACCEPTING BOYS. CONTACT US IF YOU WANT TO BE ON THE WAITING LIST

Dates: Friday 14 November at 8.00pm - Sunday 16 November at 3.00pm
At the Faith Mission Centre, Durrow, Co.Laois

Cost €52, payable at booking

For young people aged 14+ with worship, Bible teaching, good food, activities and fun.
Bring your sleeping bag and pillow. Shoes for walking and outdoor wear may also be required. Musicians, bring your instruments to help lead worship.

Parental Consent Required for Under 18’s

Contact:

Mervyn & Rachel Tomb: 0860575462
Email: midlands.irish@faithmission.org
Booking Information
Young Person's Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Age at Youth Mix*
Birth Sex*

MaleFemale
Address*

Street Address

Street Address Line 2

CityCounty

Eircode
Parent's Mobile Number*
Parent's Email

Confirmation Emailexample@example.com
Name, Address and Telephone number of your G.P.*
Emergency contact name and mobile number*
Does your young person require regular injections or tablets?*

YesNo
If "Yes" please specify
Does your young person suffer from:

DiabetesAsthmaEpilepsy or other fitsAllergies - Food or medication (Please inform us of special diets)
If any of the above are ticked, then please give details.
Has your young person been vaccinated against Tetanus?*

YesNo
If "Yes" please give date of most recent booster
Has your young person had any other serious illness in the past of which we should be aware of?
Have you any other information about your son/daughter’s health, social or learning abilities which you think we should know?
If the need arises are you happy for our First Aider to administer Paracetamol at the recommended dosage?*

YesNo
CONSENT: I certify that my son/daughter is physically fit to take part in the activities. I understand that those attending the Youthmix may go shopping with other young people without supervision. Should it be necessary, I give my consent for my son/daughter to have emergency hospital treatment and understand that I will be notified as soon as possible. I am aware that video and photos may be taken during the event which may be used in future publicity purposes.*

Consent
Parent's/Guardian's Name*

First NameLast Name
Parent's Signature (under 18s)*

Clear
Room Sharing
This young person would like to share a room with:
Payment
cost
YouthMix Cost

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EUR

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Youth Mix Booking & Consent Form

Booking Information

Room Sharing

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