STAFFS YFC DINNER DANCE 2025 Parental Permission Form

Staffordshire YFC Parental Permission - DINNER DANCE 2024

Parental Permission to attend the above named licensed event. This form is to be completed and submitted by the parent/guardian of the members aged 16-17 years. It gives consent for the member to attend and states the details of the individual (aged 18+ years and must arrive with 16-17 year old), who has responsibility for the supervision of them and 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.
DATE: Saturday 1st March 2025

VENUE: Ingestre Suite, Members Pavilion, County Showground, Weston Road, Stafford, ST18 0BD

TIME: 7pm for 7.30pm arrival, Carriages at 1am

All members attending part must have access to their current digital membership card (2024-25)

Public Health / Infection Control Responsibility:
- Please do not attend / take part if feeling unwell.
- Current government guidance must be followed at all times (this may change from the above)
Contact details for the event are County Chair – Danny Emmott 07949 530498 or YFC Mobile on 07894 174557
UNDER 18YR OLD DINERS

PLEASE NOTE PLACES FOR UNDER 18YRS DINER ARE LIMITED TO 40 AND TAKEN ON FIRST COME FIRST SERVED BASIS

Under 18yr olds – must be a current Staffordshire member aged 16+. Parent or guardian must have a completed the relevant JotForm when sending over your booking form including the supervisor details. JotForm available HERE

Supervisors may only supervise one under 18yr old

Maximum of 5 under 18's on any table - bookings received with more than 5 will not be accepted.
MEMBER DETAILS

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

Member First NameMember Surname
Member Mobile Number *
Please note this contact number may be added to the members membership record, please write n/a above if you do not wish this to happen
Date of Birth*

DayMonthYear
Date of Birth
Member Email*
example@example.com
Club Name*
Membership Number*
MEDICAL HISTORY
Does the named participant suffer from any medical conditions?*

YesNo
If Yes, give details;
Does the named participant have any allergies?*

YesNo
If Yes, give details;
Is the named participant receiving any medical treatment or on any prescribed medication?*

YesNo
If Yes, give details;
Does the participant have any disabilities and/or behavioural difficulties?*

YesNo
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.
Primary Contact - Legal Guardian*

Parent/Guardian First NameParent/Guardian Last Name
Home Phone Number (ICE1)*

Area CodePhone Number
Mobile Phone Number (ICE1)*
Please enter a valid phone number.
Will above contact be in attendance at the Dinner Dance and will be supervising the member?*

YesNo
Secondary Contact*

2nd Parent/Guardian First Name2nd Parent/Guardian Surname
Home Phone Number (ICE2)*

Area CodePhone Number
Mobile Phone Number (ICE2)*
Please enter a valid phone number.
Relationship to Child*
Will above contact be in attendance at the Dinner Dance and will be supervising the member?*

YesNo
SUPERVISER AT ACTIVITY

Parent / Guardian to provide details of the adult nominated to supervise the 16-17 years old member named above. NOTE: Must be aged 18+ years and a current Staffordshire YFC member.
Name of person to supervise 16-17 years old member:*

Supervisor - First NameSupervisor - Surname
Supervisor Mobile Telephone Number:*
Please enter a valid phone number.
Member Club Name*
Membership Number*
The above named member will take responsibility as as supervisor for the above named 16-17 year old member on the evening of the above event. They have read and understand that should there be any breaches of the SCFYFC Standards of Personal Behaviour & YFC Code of Conduct, involving the above named member then they and the above named member will be asked to leave the event and that there may be further consequences as per the policy.
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 made 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.

I understand that this is a licensed event and that my son/daughter must abide by the YFC Code of Conduct and in accordance with the Licensing Act 2003 and that should they breach any part of this policy, I will be telephoned and asked to collect my child from this event. I also give consent for the named 18+ member below, to supervise my child on the night.
Parent / Guardian Signature*

Clear
Parent / Guardian Name completing this form*

Person Completing Form (First Name)Person Completing Form (Surname)
Parent / Guardian Email*
example@example.com
Date form completed*

DayMonthYear
Date
Should be Empty:

Staffordshire YFC Parental Permission - DINNER DANCE 2024

MEMBER DETAILS

MEDICAL HISTORY

EMERGENCY CONTACTS

SUPERVISER AT ACTIVITY

DECLARATION