Participant Consents Form

Participant First Name:
Participant Last Name:
Participant Consents
Are these consents being obtained over the phone?
Guidance when obtaining consent over the phone:

- Confirm you are speaking to the right person

- Explain the above clearly and as written

- Emphasise participation is voluntary and can be withdrawn anytime

- Obtain explicit verbal consent (the participant needs to say 'yes, I consent')
Consent to Share Information
For what purpose is my information shared?
Sharing information about adults and older people in community care settings is crucial for providing effective support, helping us to work across agencies.

Similarly, "Getting it right for every child" (GIRFEC) is a Scottish policy focused on improving the well-being of children and young people by ensuring they receive the right support at the right time. A key aspect of GIRFEC is the responsible and ethical sharing of information between different agencies and professionals who work with children.

The aim of sharing information is to source and provide the right support for people at the right time. However, this sharing of information must be done with careful consideration of your privacy and consent.
What information will be shared?
For adults and older people, this information includes:
- Referrals
- Assessments
- Outcome Plan
- Service Request
For children and young people, this information includes:
- Request for Assistance
- Chronology
- Assessments
- Child/Young Person's Plan
What agencies will share my information? (relevant agencies to be selected by COVEY staff member)
If 'other' agency or person was selected above, please specify below:
Exceptions to my information being shared between the Agencies selected above:
The reasons why this information is going to be shared, what is being shared and with whom have all been fully explained to me by:
I am:
I agree to allow their information to be shared between the above agency/agencies.
I agree to allow their information to be shared between the above agency/agencies (by phone).
Participant Name:

First NameLast Name
Name of person giving consent by phone:

First NameLast Name
Participant Signature (if signing on behalf of themself):
Parent/Carer Name (if signing on behalf of their child/young person):

First NameLast Name
Parent/Carer Signature (if signing on behalf of their child/young person):
Date

DayMonthYear
Date
Name of COVEY Staff Member:

First NameLast Name
COVEY Staff Member Signature:
Name of COVEY staff member obtaining consent by phone:

First NameLast Name
Signature of COVEY Staff Member obtaining consent by phone:
Date of Phone Declaration:

DayMonthYear
Date
Medical Outing Consent
Participant's Name:

First NameLast Name
Participant's Date of Birth:

DayMonthYear
Date
Participant's COVEY Project
Do you suffer from any allergies?
Details relating to allergies:
Do you have any medical condition, or additional need that we need to be aware of?
Details relating to medication condition or additional need:
I consent to participating in events, outings and activities with COVEY. I understand that all planned activities will only take place at venues approved by COVEY who will have carried out relevant risk assessments.
I consent to participating in events, outings and activities with COVEY. I understand that all planned activities will only take place at venues approved by COVEY who will have carried out relevant risk assessments. (by phone)
I understand that COVEY must share information with Social Work and/or emergency services if a child or adult is at risk of harm.
I understand that COVEY must share information with Social Work and/or emergency services if a child or adult is at risk of harm. (by phone)
I consent to receiving emergency medical treatment, should it be required, when with COVEY staff. I also consent to COVEY holding the following medical information, in the event that treatment or additional support is required.
I consent to receiving emergency medical treatment, should it be required, when with COVEY staff. I also consent to COVEY holding the following medical information, in the event that treatment or additional support is required (by phone)
I understand it is my responsibility to ensure that any required medication is brought on any outing with staff. I also understand it is my responsibility to ensure the medication is in date. In the event of a medical emergency COVEY cannot be held responsible for the absence of the required medication.
I understand it is my responsibility to ensure that any required medication is brought on any outing with staff. I also understand it is my responsibility to ensure the medication is in date. In the event of a medical emergency COVEY cannot be held responsible for the absence of the required medication. (by phone)
I am:
Participant Signature (if signing on behalf of themself):
Parent/Carer Name (if signing on behalf of their child/young person):

First NameLast Name
Parent/Carer Signature (if signing on behalf of their child/young person):
Name of person giving consent by phone:

First NameLast Name
Name of COVEY team member obtaining consent by phone:

First NameLast Name
Signature of COVEY team member obtaining consent by phone:
Date of phone declaration:

DayMonthYear
Date
Emergency Contact Details
In case of an emergency, please insert the name and details of someone whom COVEY can contact - it is your responsibility to ensure that the emergency contact knows that their details have been given to COVEY.
Emergency Contact Name:

First NameLast Name
Emergency Contact Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Phone Number:
Relationship to Participant:
Doctor Surgery Details
Surgery Name:

First NameLast Name
Surgery Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Surgery Phone Number:
Should be Empty:

Participant Consents

Consent to Share Information

For what purpose is my information shared?

What information will be shared?

Medical Outing Consent

Emergency Contact Details

Doctor Surgery Details