Participant Consent & Information Form for Navigating Bullying

Participant Consent & Information Form for Navigating Bullying

Please fill out the form to participate in the workshop and provide necessary details.
Child / Participant Details
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender
School
Grade
Medical or psychological conditions we should be aware of
Emergency Contact Name

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent / Guardian Details
Parent / Guardian Full Name

First NameLast Name
Relationship to Child
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Physical Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Family Doctor Details
Doctor's Name

First NameLast Name
Practice Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Aid Details
Medical Aid Scheme
Membership Number
Main Member Name

First NameLast Name
Workshop Information

This workshop is a psychoeducational group intervention aimed at helping learners:
- Understand and identify bullying
- Develop assertive communication skills
- Learn safe and appropriate ways to respond to bullying
- Identify support systems

⚠️ Important:
This is not psychotherapy, but a structured educational group focused on awareness and skill development.
Confidentiality
- All personal information will be treated as confidential.
- Participants are encouraged to respect the privacy of others and not share group discussions outside the session.
Confidentiality may be limited in cases where:

 - There is risk of harm to the participant or others
 - Abuse or neglect is disclosed
 - Legal or ethical obligations require disclosure
Voluntary Participation
- Participation is voluntary.
- Participants may withdraw at any time.
- No participant will be forced to share personal experiences.
Media Consent (Optional)
I give consent for photographs/videos to be taken for educational or promotional purposes:
Parent / Guardian Consent
Parent / Guardian Name

First NameLast Name
Parent / Guardian Signature
Date Signed

MonthDayYear
Date
Child / Participant Assent
Participant name

First NameLast Name
Assent statement
Participant signature
Date

MonthDayYear
Date
Should be Empty:

Participant Consent & Information Form for Navigating Bullying

Child / Participant Details

Parent / Guardian Details

Family Doctor Details

Medical Aid Details

Workshop Information

Confidentiality

Voluntary Participation

Media Consent (Optional)

Parent / Guardian Consent

Child / Participant Assent