Annual Consent Form- Young Carers’ Activities: 1stApril2016 – 31stMarch 2017

Name of young carer
Address
POSTCODE
Contact Numbers
Emergency Contact Number for Activities:______
Email and mobile for young carer
Email and contact numbers for parent/guardian
Date of Birth of young carer:
Does the attendee currently take any medication? (e.g. inhalers)
YES / NO / Any Details:
Does the attendee suffer from any medical condition?(e.g. Epilepsy, diabetes, M.E.)
YES / NO / Any Details:
Does the attendee have any allergies?(e.g. nuts, wasp sting, penicillin)
YES / NO / Any Details:
Does the attendee have any specific requirements (e.g. dietary or access)?
YES / NO / Any Details:
Does the attendee have any additional emotional or behavioural needs that staff should be aware of?
YES / NO / Any Details:

I give my consent for this young carer to attend the Young Carers Service activities.Tick box for photographic consent □*
In the event of any emergency I give permission for medical treatment to be administered. I will also be responsible for informing The Carers Centre if and when any medications change and understand that I will need to request a revised consent form to be sent to me.

Signed______(name of parent/ guardian)

* To use the photos and video for promotion of the services provided by both The Carers centre and partner agencies in the press, newsletters and websites etc.

This consent form relates to all young carer activities undertaken at Bath & NE Somerset Carers’ Centre.

Registered Charity Number: 1060080

Registered Address: Riverside Cottages, Radstock, BA3 3PS

If you have any comments or concerns regarding this form please ring 0800 0388 885 or email

Confidentiality & Data Protection Statement:

All Bath & NE Somerset Carers’ Centre’s services are confidential, and all of the Centre’s staff, volunteers, sessional workers and students are required to sign a Confidentiality Agreement.

In certain exceptional circumstances some information may need to be passed on to other agencies. These are:

  • If there is a child protection issue
  • If we have reason to believe that your own or someone else’s safety is at serious risk

Before taking action to pass on any information we will, if possible discuss this with you.

Information you give us on this form will be used to provide your child with activities and will not be shared with any individual except to provide your child with medical help or to keep them safe. These consent forms will be stored securely then destroyed.