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GEM72 Participant information
Please provide us with the following information.
We won’t share your details with anyone unless we have to for health and safety reasons.
* Indicates required question
Email
*
Record my email address with my response
Your full name (Parent/Carer)
*
Your answer
Your address (Parent/Carer)
*
Your answer
Your email address (Parent/Carer)
*
Your answer
Your phone number (Parent/Carer)
*
Your answer
Another phone number (optional)
Your answer
Full name of Emergency Contact
*
Your answer
Phone number of Emergency Contact
*
Your answer
Participant's first names
*
Your answer
Participant's surname / family name
*
Your answer
Participant's date of birth
*
MM
/
DD
/
YYYY
Participant's address (if the same as above please enter "SAA")
*
Your answer
Participant's medical details that we should be aware of
(i.e. allergies, illnesses, medicines)
If none, please enter "none"
*
Your answer
Participant's last Tetanus vaccine (if known)
MM
/
DD
/
YYYY
Doctor's surgery name (and address if known)
*
Your answer
Please would you check the boxes to give your consent:
*
I give my consent for this Participant to take part in GEM72's activities
I give my consent for photos of this Participant to be taken for publicity purposes
I give my consent to receive details of GEM72's related events
I give my consent for GEM72 to call an ambulance and travel with the Participant if unable to reach Parent/Carer
Required
Please let us know any further information you'd like to give us. (Optional)
Your answer
Very many thanks for your time
Send me a copy of my responses.
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