W14 Youth Club - Consent Form 2023-24

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Welcome to the W14 Youth Club!

We are a community youth club for young people with a particular focus on West Kensington and Gibbs Green. The youth club is provided by St Andrew's Church (Fulham) and is a place for those of diverse backgrounds - this is a community club and therefore it is none proselytising.

The youth group is for anyone in Years 7+.

Before attending any of our youth activities. it's important that we have some emergency contact information and consent to attend from parents/guardians.

PLEASE COMPLETE THIS FORM FULLY AS REQUESTED.

THIS FORM MUST BE COMPLETED BY A PARENT OR LEGAL GUARDIAN!

Please provide parent/guardian email address in the box below - this is only so that we can send you a confirmation email of receipt of this form.

Email *

𝗗𝗘𝗧𝗔𝗜𝗟𝗦 𝗢𝗙 𝗬𝗢𝗨𝗡𝗚 𝗣𝗘𝗥𝗦𝗢𝗡

Young Person's SURNAME *

Young Person's FIRST Name *

Young Person's Date of Birth *

YYYY

Young Person's Address and Postcode *

Please include all details, this is needed for emergency situations.

Ethnicity

Asian or Asian British

Black, Black British, Carribbean or African

Mixed or Multiple Ethnic Group

White or White British

Other

Clear selection

School They Attend

School Year (as of Sept 2023) *

Please let us know about any allergies or dietary requirements and any other relevant information.

For example, "Allergic to nuts - carries EpiPen" or "Vegetarian"

Please let us know any medical conditions that your child/ward has and any other relevant information.

For example, "My child has Asthma and needs to carry their inhaler."

𝗖𝗢𝗡𝗦𝗘𝗡𝗧 𝗔𝗡𝗗 𝗘𝗠𝗘𝗥𝗚𝗘𝗡𝗖𝗬 𝗗𝗘𝗧𝗔𝗜𝗟𝗦

Emergency Contact 1 (Name) *

This should be the main parent/carer - the person completing this form.

Emergency Contact 1 (Phone Number) *

Emergency Contact 2 (Name) *

This should be someone you trust if you are uncontactable in an emergency.

Emergency Contact 2 (Phone Number) *

Parent Declaration

I give permission for the child named above to attend the youth club activities run by the W14 Youth Club (St Andrew's Church), including day trips.

I understand that at such activities my child will be under the care of the Youth Workers and approved volunteers. I also understand that whilst all staff and volunteers will take all reasonable care, they cannot be held responsible for any loss, damage or injury suffered during or as a result of activities.

I give permission for my child to leave the event without a parent/carer.

In an emergency and/or I am uncontactable, I am willing for my child to receive necessary medical treatment including anaesthetic.

I agree to the above 'Parent Declaration' *

Yes

Photo Consent *

Are you happy for your child to feature in pictures and videos which will be used for church publicity.

Yes

Parent/Guardian Name (Adult Filling out this Form) *

Parent/Guardian Email Address: *

Thanks for taking time to complete this important form! We're really looking forward to your child joining us. Please get in touch if you have any questions.

Jacob Holme
Youth Worker

Tel: 0203 375 6595
Email: jacob@standrewsfulham.com

Your details will be stored safely in both print and digital versions. You can find our privacy notice here: www.standrewsfulham.com/data-protection

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms