Blue Square Consent Form

1

Young persons name* This field is required.

First Name

Last Name

2

Young persons age* This field is required.The project is open to young people aged 12-18

3

Young persons shoe size* This field is required.(For steel toe work boots)

4

Young persons emailTo get in touch about further opportunities

5

Parent / Carer's name * This field is required.

First Name

Last Name

6

Parent / Carer's mobile* This field is required.

7

Parent / Carer's email* This field is required.

8

Please state any known allergies or medical conditions or additional needs that Build Up’s staff should be made aware of

9

I authorise Build Up staff to obtain medical advice in an emergency and give consent for emergency medical treatment for my young person if I cannot be contacted at the time.* This field is required.

Yes

10

I consent for still and video photography to be used to document and promote this project by Build Up and partners involved* This field is required.

Yes

No

11

Would you like to be contacted by Build Up about future opportunities?* This field is required.

Yes

No

12

Would you like to be contacted by Sounds Like Chaos about future opportunities?* This field is required.

Yes

No

13

I give permission for the named young person to take part in the project.* This field is required.Sign here:

Clear