Brackley Senior Youth Club
South Northants Youth Engagement (SNYE) run Brackley Senior Youth Club at Brackley Leisure Centre is for SCHOOL YEARS 7 to 10.
Young Person's Name:
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First Name
Last Name
Date of Birth
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Age
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name 1:
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First Name
Last Name
Emergency Contact Number 1:
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Emergency Contact Name 2:
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First Name
Last Name
Emergency Contact Number 2
*
Does your child have any allergies/illnesses?
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Is there anything else you feel we should know that will help us to support your child? Eg. Additional needs, disabilities, fears/phobias, social anxiety. This information will be kept confidential, we would like to work with you to ensure we offer the best support to you & your young person without judgment.
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In case of an emergency, do you give us permission to seek medical help straight away?
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Yes
No
I agree to my child attending the Youth Club. I acknowledge the need for responsible behaviour and if my child does not follow the groups agreement, then they may be asked to leave.
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Yes
No
Is the young person allowed to leave the Youth Club without an adult?
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Yes, at anytime by themselves.
Yes, at the end of the session by themselves.
Yes, at the end of the session, only with a group of friends.
No, they MUST be collected by an adult.
Who will your young person be collected by? PLEASE LIST ALL ADULTS
Do you allow photo consent for your child, photos will only be used on our social media platforms and website?
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Yes
No
What school does your young person attend, or are they home schooled?
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Parent/Carer Email
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example@example.com
Signature
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Date
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-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Print Name:
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Submit
Submit
Should be Empty: