Connect Berwickshire Consent Form

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In the event of an emergency, it is important that the person in charge of the group has the necessary information about any medical condition that could affect the participation or treatment of the below. All information requested will be treated in strict confidence, and will not necessarily prejudice the inclusion of the person named below in the activity. It is in the interests of the above that full and accurate information be given and that you notify us of any change in circumstances that might affect participation.

This consent form covers your child or ward for all drop in sessions and activities through Connect Berwickshire.

Area your child/Ward will be attending? *

Eyemouth

Coldstream

Duns

Name of Participant *

Age of Participant *

Date of Birth of participant *

YYYY

Home Address *

Phone Number *

Alternative Telephone number for use in emergency *

Has the above named person had recent surgery or been in contact with any infectious or contagious diseases? (Including Covid-19) Please give description. *

Has the named above any known allergies? (Medication or foods?) *

Is the above named person currently undergoing treatment by a Doctor? please give details including any medication? *

Has the above named person received a tetanus injection within the last ten years? *

Yes

Has the above named person any medical condition which a doctor should know about before carrying out treatment(eg Asthma) *

Is there any activity in which the above named person may NOT participate? (eg swimming) *

Is there any additional information we should have or know? (ADHD, travel sickness, diet, diabetes, etc?) *

Liability Insurance

Liability Insurance will meet claims resulting from accidental injury or damage to property if it is proved it was caused as a result of negligence on the part of Connect or a Connect employee. Participants wishing to obtain cover for personal accident and Third Party Liability are advised to contact an insurance company or broker.

Data Protection

Connect will ensure that your personal information will not be shared with third parties. For full details of the organisation’s data protection & GDPR compliance can be requested to the manager. david@bypconnect.com

I give my consent for my child to take part in the activities available through Connect Berwickshire, which includes minibus/public transport, outings, visits and outdoor and indoor activities. *

Yes

I give permission that photograph/video images may be taken and used for evaluation and advertising purposes by Connect? *

Yes

Parent/Guardian Declaration (For under 16s)

I have read the information issued concerning the activity and the statement of insurance. I understand the nature of the activity/activities to be undertaken and consider my child/ward fit to take part. They do not suffer from any medical condition not stated above. I hereby consent to the submission of the above named to emergency medical or surgical treatment including the administration of anaesthetic or blood transfusion as considered necessary by the medical authorities present. I am happy with the data protection policy and understand Connect's policy on data protection. I understand that should my child/ward misbehave or act in a manner that causes damage or destruction that I am liable for these costs.

I have read and understood the above declaration. *

Yes

Parent/Guardian full name. *

Drop ins

Thank you for filling out the above consent form. Our Drop ins will now operate as follows:

Young people who attend the drop ins in all 3 of our areas, will have the freedom to come and go as they please, it is the parents/guardian responsibility to ensure their child/ward has been made aware if you wish for them not to leave during the hours of operation. Ensure that you have made our staff aware, we are unable to prevent your child/ward from leaving however we can contact you if they leave and you have made the staff aware that they are not to leave.

Parents/Guardians who choose to pick their child up from our drop ins, please remain outside the building unless there is a reason you need to come in and speak to staff members.

Submitting the Date will act as recognition of an E-signature. *

YYYY

Any further questions.

If you have any further questions in regards to our organisation or the activities please contact us via:

You will not receive a confirmation email the programme is a drop in service where you can bring your child/ward along at anytime during the session hours. This consent will cover your child/ward for all the summer programme sessions.

Manager: David Shields
Email: david@bypconnect.com
phone number: 07752396691

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