Youth Club Juniors Application Form
This information is kept confidential. Some data will be shared with our funders but no names and address.
Child details
Name
*
First Name
Last Name
Date of Birth (Please note your child must be 8-13 to join)
*
-
Month
-
Day
Year
Date
Child's school
*
Child's gender
*
Please Select
Male
Female
Non Binary
Ethnicity
*
Please Select
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian Background
Caribbean
African
Any other Black, Black British or Caribbean Background
White and Black Caribbean
White and Black African
White and Asian
Any other mixed or multiple ethnic background
English, Welsh, Scottish, Northern Irish or British
Irish
Gypsy or Irish Traveller
Any other white background
Arab
Any other ethnic group
Prefer not to say
I want to sign up a sibling: Name
First Name
Last Name
Date of Birth (Please note your child must be 8-13 to join)
-
Month
-
Day
Year
Date
Child's school
Parent/carer details
Name
*
First Name
Last Name
Parent/ Carer Phone Number
*
07989912345
E-mail
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact 1 (we will only contact this person if we cannot get hold of the main parent contact in an emergency)
*
Name
Number
Relationship to child
State / Province
Postal / Zip Code
Do you receive universal credit?
*
Yes
No
Is your child on Pupil Premium?
*
Yes
No
Does your child require any additional support you feel would be helpful for us to know so we can support your child in the most appropriate way, for example autism, ADHD, new to learning English. If so, please give details. If none, please state none.
*
Does your child have any medical or mobility issues? If so, please give details of medication such as inhalers, epipens.
*
During the sessions we will be feeding the children. Please state here if your child as any dietary requirements, for example Vegan, Halal OR if they have any food allergies. If none, please state none.
*
How did you hear about the Youth Club?
*
Please Select
Flier
Banner
Whatsapp group
Through your school
Grand Junction social media
Grand Junction website
Grand Junction newsletter
Word of mouth / friend
Other
Are you happy for your child to be photographed for future promotion on Grand Junction's website and social media?
*
Yes
No
Do you want your email added to our mailing list? We will email you once per month with information on other projects at Grand Junction.
*
Yes
No
Tick if you give permission for your child to go home by themselves
*
My child can leave by themselves
My child cannot leave by themsleves
If you want someone other than you to pick up your child, please enter the name of the adult collecting them, and relationship to child
*
Parent/carer Signature
*
Submit Application
Should be Empty: