IMPACT Youth Consent Form
For secondary school aged young people.
Organisation(s) attending:
*
IMPACT Youth (Friday night @ Ballycarry Presbyterian)
Name of young person (siblings can be added in below)
*
First Name
Last Name
Date of birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
*
Year group in school:
*
If applicable - sibling #2. Name of young person
First Name
Last Name
Date of birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Year group in school:
If applicable - sibling #3. Name of young person
First Name
Last Name
Date of birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age:
Year group in school:
Name of parent/guardian
*
First Name
Last Name
Address:
*
Contact telephone number:
*
Email:
*
If I cannot be contacted, please contact (please write name and phone number):
*
YOUTH regularly sends out parent messages on WhatsApp regarding upcoming events, or last minute changes. Do you give permission to be contacted via WhatsApp by the Leader in Charge?
*
Yes
No
Do you give permission for your young person (age 16 plus) to be group messaged by our youth Whatsapp number about upcoming events, or last minute event changes? Our messaging policy is strictly "communication NOT conversation"!
*
Yes
No
If yes, please insert your young person's mobile number :
Do you give permission for photographs and video to be taken of your child for Islandmagee/Whitehead/Ballycarry Presbyterian publicity and programme updates?
*
Yes
No
In the event of illness or accident, having parental responsibility, I give permission for first aid to be administered where considered necessary by a first aider. In the event of a medical emergency, leaders will endeavour to contact you as soon as possible using the contact numbers given.
*
Yes
No
Please indicate any medical conditions, additional needs, allergies, or anything else which would be helpful for the leaders to know about:
I will inform the leaders of any important changes to my child's health, medication or needs and also any changes of address and telephone numbers listed above...
*
Yes
No
I give permission for IMPACT YOUTH to securely store the contact details in this form for 12 months
*
Yes
No
Signature of Parent/Guardian
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Thank you for signing up for IMPACT Youth.
We look forward to welcoming you along! For more information please do not hesitate to contact Katherine Dickson (Youth Worker) on 07851665460 / katherine.islandmageepci@gmail.com. This data is being submitted to IMPACT YOUTH through a third party which is GDPR compliant.
Submit
Should be Empty: