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Rock Climbing Permission Form 2022
By completing this form you are confirming you are giving permission for your young person to attend our Rock Climbing event at Wycombe Leisure Centre on the 3rd August 2022.
More information is available at
https://www.placesleisure.org/centres/wycombe-leisure-centre/centre-activities/climb/
Rock climbing is a physical activity; please ensure that young people are wearing appropriate clothes and footwear.
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* Indicates required question
Details of Young Person
Name of Young Person
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Details of Parent or Guardian
Parent/Guardian Full name
*
Your answer
Relationship to Young Person (eg. parent)
*
Your answer
By checking this box I agree to the named young person attending Rock Climbing at Wycombe Leisure Centre on the 3rd August 2022.
*
I Agree
Required
Emergency contact details
In an emergency on the 3rd August, I may be contact on the following:
Telephone (Home)
Your answer
Telephone (Mobile)
*
Your answer
If I am not available on the above, please contact:
Full name
*
Your answer
Telephone
*
Your answer
Relationship to young person
Your answer
Medical Information about Young Person
Any conditions requiring medical treatment, including medication?
Your answer
Please outline any special dietary requirements or allergies?
Your answer
Any medication allergies?
Your answer
Do they suffer from any mental health or additional behavioural needs?
Your answer
Medical Declaration
By checking this box I agree to the named young person receiving medication as instructed and any urgent dental, medical, surgical treatment, including anaesthetic or blood transfusion as considered necessary by the medical authorities present.
*
I agree
Required
Data protection
All information provided on this form is held in the strictest confidence and is destroyed after two years. Information provided to Risborough Youth Club is not shared with any other third parties with the exception of relevant public authorities for the purpose of child protection and safeguarding.
Photographs and videoing
We would like to obtain your consent for photographing/videoing your ward/son/daughter. These photos and videos will be used to promote the work we do with young people, for example display boards at the club.
Consent
I do consent to photographs or videos to be taken
I do not consent to photographs or videos to be taken
Additional information
Is there any other information that would be helpful for us to know?
Your answer
If any changes to the information you have supplied change, please notify Risborough Youth Club immediately.
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