Brackley Junior Youth Club
Brackley Junior Youth Club is for school years 5-7 and run by South Northants Youth Engagement (SNYE). If you have any queries, please contact SNYE Youth Engagement Manager, Penny Embden on 07816 466134.
Young Person's Information
Young Person's Name:
*
First Name
Last Name
Date of Birth
*
Age
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Name
*
Emergency Contact Details
Emergency Contact Name 1:
*
First Name
Last Name
Emergency Contact Number 1:
*
Emergency Contact Name 2:
*
First Name
Last Name
Emergency Contact Number 2
*
Medical & Additional Information
Does your child have any allergies or illnesses?
*
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.
In case of an emergency, do you give us permission to seek medical help straight away?
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Yes
No
Agreement & Photo Consent
I agree to my child attending the Youth Club. I acknowledge the need for responsible behaviour and if my child does not follow the group's code of conduct, then they may be asked to leave.
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Yes
No
Do you allow photo consent for your child, photos will only be used on our social media platforms & in promotional material?
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Yes
No
Leaving Youth Club
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 with a group of friends
No, will be collected by an adult (Please list ALL adult names)
Who will your child be collected by? (Please list ALL names)
*
Sign & Date
Print Name:
*
Parent/Carer Email
*
example@example.com
Signature
*
Today's Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Submit
Submit
Should be Empty: