iNSPiRE - Youth Empowerment Programmes

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iNSPiRE - Youth Empowerment Programmes - Enrolment Form

Contact & information sheet (mainly for emergencies and to get to know your young person so we can tailor the programme to best suit the young people attending).

Email *

Untitled Title

Programme Title: *

Untitled Title

Programme Dates: *

Young Person's Name: *

Date of Birth: *

YYYY

Age: *

Gender *

Female

Male

Other:

Address: *

Which school, if any, does your young person attend? *

Primary Contact Name: *

Primary Contact Phone Number: *

Primary Contact Email Address: *

Secondary Contact Name: *

Secondary Contact Phone number: *

Secondary Contact Email Address: *

Emergency Contact Name: *must be different to first 2 contacts *

Emergency Contact Phone Number: *

Emergency Contact Email Address:

Please give details of any medical conditions or any known allergies: *

Is your young person currently on any medications? *

Yes

Medication details:

Do you give permission to administer panadol/antihistamines if necessary? *

Yes

To make it easier to tailor each programme to the young people attending, please describe your young persons personality... *

Have they ever participated in anything like iNSPiRE before? *

Yes

Maybe

Do you give permission for any media (photos/videos) of your young person taken during the programme to be used for website and promotional purposes for iNSPiRE? *

Yes

Do you agree to pay the deposit required for the relevant programme(s) your young person is wanting to attend in order to secure their place? *

Yes

Any comments:

Send me a copy of my responses.

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