Cabra For Youth Clg
Youth Service Registration Form 2026
Personal & Contact Details
Young Person's Name
*
First Name
Last Name
Date Of Birth
*
-
Day
-
Month
Year
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Current Date
-
Day
-
Month
Year
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Current Age ( Automatically Inputs)
Address of Young Person
*
Street Address
Street Address Line 2
City ( Example Dublin 7 )
State / Province
Eircode
Gender
Name of School / Training / Employment
*
Please select the Area within Cabra the Young person lives
*
West
East
Dunard
Other
Phone Number of Young Person
*By providing the Child/Young person’s mobile number you are consenting to contact from the Cabra for Youth Staff on issues relating to the project and its programmes via messaging services.
Format: (000 000 0000).
Emergency Contact Details
Parent / Guardian Name
*
First Name
Last Name
Parent / Guardian Phone Number
*
Please enter a valid phone number.
Format: (000 000 0000).
Second Emergency Contact Name
*
First Name
Last Name
Second Emergency Contact Number
*
Please enter a valid phone number.
Format: (000 000 0000).
Second Emergency Contact Relationship to Young person
*
Eg , Sister , Uncle Grandparent etc
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Medical / Additional Need Details
This is sensitive information. Do you consent to Cabra for Youth to have access to this information?
*
Please Select
Yes
No
Any Medical Conditions / Allergies?
*
No
Yes ( Please give details )
Is taking Medication
*
No
Yes ( Please give details )
Any Dietary Requirements
*
No
Yes ( Please give details )
Has had a Tetanus ? (Please give information as to when it was given last)
*
No
Yes ( Please give details )
Any Other Additional Needs?
*
No
Yes ( Please give details )
In the case of an emergency staff will do everything reasonable to contact the parent/guardian named above. In circumstances where medical treatment is required immediately and where it is not possible to contact those named on this form, I authorise any of the staff members of the youth service to refer my child to a medical professional or emergency services or administer First Aid on my/our behalf
*
Yes
No
Note :
Due to our funding criteria and insurance restrictions we regret we cannot accept a Child/Young Person under the age of 10years and we will not accept any liability for a child where a false declaration is made on this application particularly in regard to a child’s/young person’s age.
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Consent
Consent to participate in Cabra For Youth Clg
The youth service provides a range of non-formal education programmes and activities for young people. These include weekly project based programmes, Drop Ins, Youth Forums, Interest groups, Residential, Youth exchanges, Adventure Sports and Water Sports.
*
Rows
Select One
I consent to my child participating in
activities with Cabra for Youth
Yes
No
My child can
swim 25m (1 pool length) or more
Yes
No
I consent to the use of images all social media platforms including via phone and text messaging
Yes
No
Consent for Photograph / Video use
In the course of the programmes run by the youth service, youth workers and young people may take photographs or video footage. I understand these will only be used for appropriate display publications as approved by management of the youth service.
Use of Images Consent
*
Rows
Select One
I consent to the use of images and videos being displayed in the youth service
Yes
No
I consent for use of images & videos in Brochures
Yes
No
I consent to the use of images on all social media platforms including phone and text messaging
Yes
No
I consent for use of images in grant applications
Yes
No
Technology Access
The youth service provides young people with access to computer technology and age appropriate internet usage. I understand that every reasonable precaution will be taken by the youth service to provide for online safety.
Technology Access Consent
Rows
Select One
I consent to my child / Young person to using electronic devices which may include laptops , PC’s and tablets which may have internet access.
Yes
No
I consent to my child / Young person to engaging with the youth service online , this may including online gaming or video calls e.g. zoom calls
Yes
No
Anti-Social Behaviour Policy
The youth service does not tolerate the involvement of young people in alcohol, drugs and/or sexual activity whilst engaging in activities with the service. If found to be engaging in any of the above, the parent/guardian will be contacted and that young person asked to leave the activity. I agree to the above policy
*
Yes
No
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I hereby declare that the information supplied in this registration form is accurate at the time of signing and that I will inform the staff of CABRA for Youth immediately of any changes to the above details should they occur.
*
Yes
No
Please sign Below ( Parent / Guardian )
*
Date of being Signed
*
-
Day
-
Month
Year
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Young Person Over the Age of 18 years of Age Sign Below
Please sign Below (Young Person over the age of 18 years of age )
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