Young Hackney
London Borough of Hackney
HSC, 1 Hillman Street
London E8 1DY
020 8356 1063
5th February 2018
Dear Parent/Carer
Forest RoadJunior Spring Half Term Programme
Forest Road Junior (8-12 years) Spring Half TermProgramme will be running from 10.00am- 3.00pm daily from Monday 12thFebruaryto Friday 16thFebruary2018.
All of our activities are FREE but we do request that you provide your child/young person with a healthy packed lunch each day they attend. We are working on exploring obesity and healthy eating as part of our programme with young people. We encourage parents/carers to review their child’s/young person’s pack lunches.
Please complete and return the attached consent form to reception by Friday 9thFebruary 2018, if you would like your child/young person to take part in the programme.
We will be taking young people on trips during this period. The trips are allocated to young people dependent on the number of sessions attended, behaviour, reward systems and the date the permission slip is returned. Letters for trips will be provided closer to the trip dates.
If you have any questions or require any more information please do not hesitate to contact me.
Yours Sincerely,
Modi Abdoul: YH Team Leader
Consent Form for Young HackneySpring Half Term Programme: Monday 12th February to Friday 16thFebruary 2018
The personal information that is provided on this form will be handled by the London Borough of Hackney in accordance with the Data Protection Act 1998.The information provided will be used for the purposes of conducting day trips and Off-Site Activities. This information will only be used for these activities and their related purposes. The information provided by parents/carers will be disclosed to emergency contact officers and host facilities where appropriate (i.e. dietary requirement)
If there are any questions you wish to ask or if you need help in completing this form please do not hesitate in asking one of our staff.
Section A: Personal Details of Young Person/Child:
First name: / Gender: / Male / FemaleSurname: / Date of Birth
Full Address: / Age:
Post code:
Young person Mobile Number:
Email:
Section B: Medical information of Young Person/Child:(please circle yes or no and provide details)
(1)Does your child suffer, even mildly, from any conditions (such as epilepsy, asthma, diabetes, heart condition or allergies, food allergies) requiring medical treatment, including medication?
YES or NO (details) ………………………………………………………………………………….…………………………..…..…
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(2)Does your child have any dietary requirements? YES or NO (details) ………………………………………………………….…
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(3)Does your child take any regular medication? YES or NO (details) ………………………………………………………………
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(4)To the best of your knowledge has your child been in contact with any contagious or infectious disease or has suffered from anything in the last four weeks that might become contagious or infectious?
YES or NO (details)……………………………………………………………………………………….…………………….…………
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(5)Does your child have any Learning or Physical disability? YES or NO (details) ………………………………….……………
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(6)Does your child have Special Education Needs? YES or NO (details) ……………………………………………..……......
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(7)Does your child have any additional support needs? YES or NO (details) ………………………………………………….
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(8)Are there any activities in which your child cannot participate? YES or NO (details) ……………….……………………….
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(9)Is your child allergic to any medication? YES or NO (details) ………………………………………….……......
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(10) Is there additional information regarding health and additional needs you would like to share with the us:
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Section C: Parent/Guardian/Carer Details
Carer/Parent Name: / Landline/workEmail: / Mobile:
Carer/Parent Name: / Landline/work
Email: / Mobile:
Do you consent to text alerts during our offsite trips (Please tick): / Yes / No
Would you like to be added to Young Hackney Mailing list (Please tick): / Yes / No
Landline/work
Mobile:
If not available contact:
Name:______
Address: ______
Relationship to Young Person:
______
Section C: Parent/Guardian/Carer Declaration
Young Hackney Spring Half Term Programme will be running from Monday 12thFebruary to Friday 16thFebruary 2018 (juniors: 10.00am- 3.00pm) (seniors: 4:00pm to 8:00pm). I hereby consent to the attendance of my child/the child in my care to Young Hackney Youth Hubs and Young Hackney Half Term Activities both within and outside of the Youth Hubs on the above dates. I recognise that the accompanying staff will be responsible for her/his supervision and care as far as can be reasonably expected.
I understand that unlike Term Time youth provisions (i.e. evening Youth Clubs), any offsite trips is not “open access” and my child/the child in my care may not join and leave the activity as s/he pleases.
I understand that if my child/the child in my care behaves in a purposefully disruptive or otherwise inappropriate manner whilst on and off-site,they will be withdrawn from the activity. I am aware that under these circumstances it will be my responsibility to collect them and/or arrange for their transportation home. I am aware that I will be deemed responsible for any additional expenses incurred by the Centre as a result of this occurring and that LBH will bear none of the costs.
I further consent that the staff may give permission for any urgent medical or surgical treatment including the administration of local or general anaesthetic, for my child which is considered necessary by a qualified medical practitioner during the course of the Holiday program.
Name of Parent (please print)______
Signature: ______Date: ______