Summer Programme 2015
Please tick which activity your child would like to attend
Wednesday 22nd July 2015
Ice Breaker, Life Science Centre, Newcastle
Wednesday 29th July 2015
Treasure Trail at Tynemouth, Beach
Wednesday 5th August 2015
Kirkley Hall Zoological Gardens, Ponteland
Wednesday 12th August 2015
Sport Activities, Newcastle
Wednesday 19th August 2015
Fun Factory (roller skating), Newcastle
Meeting Point – 10am at 5th Floor, Mea House, Newcastle
Pick Up Point – 4pm at 5th Floor, Mea House, Newcastle NE1 8XS

2. Child’s name

I agree to ______(young person’s full name)

Date of Birth: ______taking part in this programme.

I agree to ______’s participation in the activities described. I acknowledge the need

for ______to behave responsibly.

3. Medical information about your child

a)Any conditions requiring medical treatment, including medication? YES/NO

If YES, please give brief details:

b)Please outline any special dietary requirements of your child and the type of pain/flu relief medication your child may be given if necessary:

c)Is your son/daughter allergic to any medications, food, drink or other substances? YES/NO (If YES, please specify)

d)Please let us know if your child has any physical or mobility issues that will require any additional support or mean that they might be restricted in what they can do?

4. Media consent

Whilst young people are taking part in activities organised by our service we occasionally like to record an event or activity by taking photographs or using a video camera. The images may be used for reports, displays, and evidence for accreditation or even just as memories for the children.

If you are happy for Becoming Visible to photograph/film you/your son/daughter during the normal course of an activity please complete the form below:

Photo albums
Displays
Reports/evaluations
Printed publications available to the public
BV website
Newspaper articles
Accreditation

Other than for accreditation purposes young people’s full names will not be given in any publication. However if you are happy for their full name to appear in newspaper articles please tick this box:

If you do not wish for your child to be photographed or filmed at any time during their time on an activity with Becoming Visible then please tick this box:

4. Contact details

Name
Address (including postcode)
Mobile or Telephone Number
Email address
Emergency Contact Name
Emergency Contact Tel/ Mobile no

5. Declaration(Your child’s place will not be booked if the declaration is not signed)

I have received full and sufficient information telling me about the visit and the activities that my son/daughter will be undertaking.

I agree to my son/daughter receiving medication as instructed and any emergency dental, medical or surgical treatment, including anaesthetic or blood transfusion, as considered necessary by the medical authorities present.

I understand the extent and limitations of the insurance cover provided.

Name: ______

Signature: ______

Relationship to the child: ______

PLEASE POST OR EMAIL THIS FORM TO US –

A copy of this form will be held securely by the group leader for this visit.

(The master copy will be retained securely in the BV Youth Office

for the duration of the summer programme.)

Becoming Visible, 4th Floor, Mea House, Ellison Place, Newcastle upon Tyne, NE1 8XS

Telephone: 0191 2330999 Fax: 0191 2331334 Email:

Registered Charity Number: 1117872 Company Number: 5291167