Young Carers Parent/Guardian Consent Form
If you are under 16 years of age (or not legally able to give consent) a parent or guardian should complete this form. By signing this form and ticking what you consent to, you are providing consent for your child/young person to join the range of services provided by Young Carers Bedford Borough; this complies with GDPR 2018.
Young Carer Full Name:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Contact Number
*
-
Area Code
Phone Number
Young Carer Contact Number
-
Area Code
Phone Number
Parent/Guardian Email Address
*
Young Carer Email Address
Young Carer School/College/University
*
Young Carer GP Surgery
*
Does the young carer have any medical or support needs, we should be aware of? If yes, please answer the next question.
*
Yes
No
What medical or support needs does the young carer have? Please tells us about any treatment, medication, dosage or side effects.
Does the young carer have any allergies or dietary requirements? If yes, please answer the next question.
*
Yes
No
Please tell us about any allergies, symptoms and treatment, and dietary requirements.
Emergency Contact Details
Please provide the details for at least one person who can be contacted in case of emergency.
Emergency Contact 1
Full Name:
*
Relationship to Young Carer
*
Contact Number
*
-
Area Code
Phone Number
Email Address
*
Emergency Contact 2
Full Name:
Relationship to Young Carer
Contact Number
-
Area Code
Phone Number
Email Address
Declaration
Please select yes or no as appropriate.
I am in agreement for my young person to receive Basic First aid and any necessary emergency medical treatment and therefore, authorise a member of the young carers team to sign on my behalf any written form of consent required by hospital authorities should any medical treatment be necessary, provided I the Parent or Guardian is absent and every possible effort made to contact me.
*
Yes
No
I grant Young Carers Bedford Borough and Carers in Bedfordshire the right to use my/or my young person's imagery and/or recordings in promoting the organisation on its website, in publications, on social media, marketing materials, displays or in the media.
*
Yes
No
I agree to receive emails and text messages for the purpose of being informed of activities or services from Young Carers Bedford Borough.
*
Yes
No
I agree to inform Young Carers Bedford Borough of any changes in this information prior to my young person attending any activity or event.
*
Yes
No
I agree that a member of the Young Carers Bedford Borough team can contact my young person directly.
*
Yes
No
I am in agreement for my young person to receive one to one support if assessed as required and understand that I will be informed of when this will take place.
*
Yes
No
I agree for a member of the Young Carers Bedford Borough team to visit my young person at school to complete the young carers assessment and to share any information with the school, as necessary, including their name for the schools young carer census.
*
Yes
No
I agree to notify the Young Carers Bedford Borough team if my young person will not be attending a club or event if they have been confirmed as attending.
*
Yes
No
I give permission for my young person's school to be made aware that they are registered as a young carer with Young Carers Bedford Borough.
*
Yes
No
Young Carers Team Contact Information
Telephone number: 0300 111 1919. Email address: hi@youngcarersbedford.com
Submit
Should be Empty: