Health questionnaire & Digital Release
For under 16's
Please complete this form before attending any workshop.
This information will be stored and used in line with GDPR and will not be shared with other parties. The information you give is kept confidentially. We will NOT contact you for marketing or promotional purposes and will never share your information with any third party without your permission.  
Please note that until we receive a signed copy of this form you will not be able to participate in any live classes.

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Student: Name *
Student's Date of Birth: *
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Next of Kin: Name *
Email Address *
Contact Number *
Digital Media Consent
For use of digital media (photographs, videos, etc.) of children, adults and vulnerable people.
Fiery Jacks C.I.C. takes the safeguarding of all of its learners very seriously and protects the privacy of its students and will never disclose any personal information. This form is for the purpose of any media inclusion specifically relating to Fiery Jacks C.I.C.
Occasionally, we take photographs and videos during our projects. We may use these images on our website, social media, printed publications, and fundraising materials. We may also make video and audio recordings for the above purposes or other educational use. We will only ever use this media in a responsible and appropriate manner.
To comply with the Data Protection Act 1998, we need your permission before we can photograph or make any video recordings.
I hereby give Fiery Jacks C.I.C. permission to use any still and/or moving imagery, video footage, photographs, and audio footage depicting the student named for the following uses:
Fundraising
Website and Social Media
Teaching and training purposes
Printed publications, e.g flyers/posters etc.

Digital Media Consent *
Health and Physical Readiness Form
The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people.
Please fill in your child's medical details:

Has your doctor ever said that you have a heart condition OR high blood pressure ? *
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity? *
Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *
If you answer Yes, please give further details below.
Are you currently taking prescribed medications for a chronic medical condition? *
If you answer Yes, please give further details below.
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue  (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. *
If you answer Yes, please give further details below.
Has your doctor ever said that you should only do medically supervised physical activity? *
Please list any conditions or medication here:
Is there any other medical information you think we should know about your child?
Parent/Guardian Signature: *
Parent/Guardian Printed Name *
Today's Date *
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Safeguarding Info:
Our Policies are available on our website: www.fieryjack.com
Reporting any incidence of safeguarding will be done on our Safeguarding Reporting Form, which will be reviewed by a Director: https://docs.google.com/document/d/1J-dPvDGRvp7LIuXtVIfECV2d08LopgtSb0JjtqH1bg/edit?usp=sharing 

We also have an anonymous contact form here for people to fill in if they feel they cannot voice their concerns in person:
https://forms.gle/shxMshUVy3qiBUvU9 
This is all directed straight to our Safeguarding officer.
Contact Details:
Designated Child Protection Lead
Gordon Tyler
07752853466/fieryjacksonlinecircus@gmail.com 
Designated Child Protection Deputy
Harriet Rose
07521988541/harrietsown@gmail.com 

NSPCC Helpline: 0808 800 5000
We are committed to reviewing our policy and good practice annually.

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