RUGBY THRIVE CONSENT FORM

Parent/Carer Consent & Registration Form
Location: Hill Street Youth and Community Centre
Funded by: The National Lottery Community Fund

Please complete all sections in BLOCK CAPITALS.
1. Child/Young Person Details
Full Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age:
Gender:
Ethnicity:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Postcode:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Parent/Carer Details
Parent/Carer Name:

First NameLast Name
Relationship to Young Person:
Telephone Number:

Area CodePhone Number
Email Address:
example@example.com
Emergency Contact Name (if different):

First NameLast Name
Emergency Contact Number:

Area CodePhone Number
3. Medical Information
Please provide details of any medical conditions, allergies, dietary requirements, disabilities or additional needs we should be aware of:

I understand and agree to these expectations.
9. Data Protection
Information provided on this form will be used solely for the safe delivery and administration of the programme and will be stored securely in line with data protection regulations.
I consent to Hill Street Centre storing and using this information for programme purposes.
10. Parent/Carer Declaration
I confirm that the information provided on this form is accurate to the best of my knowledge
Parent/Carer Signature:
Print Name:

First NameLast Name
Date:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty: