Orangebox want to ensure that all young people who attend events and activities have a great time and are free to take part in everything that interests them.
We also give a high priority to the safety of the children and young people. To ensure that we can effectively ensure your safety, all children and young people must register with us using this form.
If you are under 16 years of age, you must get your parent/guardian to also sign the form.
The information you provide will contribute towards evidence that we are achieving outcomes.
Any information you give is covered by the data protection act and used purely for monitoring and statistical purposes.
ABOUT YOUFull Name:
Date of birth: (We need to know your age as some activities have age restrictions)
How would you describe yourself? (please choose from the options below)
Gender: Male Female Rather not say
Ethnicity (This information helps us ensure we provide suitable activities for all children and young people from all areas of our community)
Asian/Asian British - Bangladeshi / Mixed - White and Asian
Asian/Asian British - Indian / Mixed - White and Black African
Asian/Asian British – Pakistani / Mixed - White and Black Caribbean
Asian/Asian British - Any Asian background / Other Mixed Back-ground
Black/Black British – African / White - British
Black/Black British – Caribbean / White - Irish
Black/Black British - Any Other Background / White - Traveller of Irish Heritage
Chinese / White - Any Other Background
Roma
Rather not say / Any Other Ethnic Group
Religion or Belief (This information helps us ensure we provide suitable activities for all children and young people from all areas of our community)
Buddhist / Muslim
Christian / Sikh
Hindu / No religion
Jewish / Other religion
Are you currently in: Education/ Training/ Employment? (Please state below)
Where?
Your Home
Address:
Postcode:
Home phone:
Mobile phone:
Email address:
Your Health
(Please state any medical conditions i.e. Allergies, Asthma, Diabetes, Attention Deficit, Mental Health issues etc, and any medicine the participant may have with them i.e. inhaler etc)
……………………………………………………………………………………………………………………
Do you consider yourself to have any disabilities? Yes / No
In the event of an accident do you give permission to apply basic first aid Yes / No
(Delete as appropriate)
YOUR EMERGENCY CONTACT INFO
1) Parent/Guardian Name:
Emergency contact telephone:
Relationship to young person named:
Email:
Address:
2) Parent/Guardian Name:
Emergency contact telephone:
Relationship to young person named:
Email:
Address:
How did you find out about us?
Please tick here if you DONOT want to join our mailing list
YOUR AGREEMENT
To be completed by you (if 16 or over) / PARENT/ GUARDIAN AGREEMENT
To be completed by the Parent / Guardian (if under 16)
Mark box if you agree to the terms below.
I agree to be photographed/ filmed at Orangebox during activities and understand these images will be used for evaluation, promotion and reporting purposes.
I understand Orangebox is a centre for all young people and I will people with respect and fairly, as I would expect to be treated myself.
I will look after Orangebox and the equipment inside.
Signature: / Mark box if you agree to the terms below.
I give my child permission to be photographed/ filmed at Orangebox during activities and understand these images will be used for evaluation, promotion and reporting purposes.
I give permission for my child to receive first aid from a trained member of staff in the case of an accident.
I give permission for this information to be stored and recorded for safety, reporting monitoring and evaluation purposes.
Signature:
Pease return this completed to:Orange Box young people's centre, 1 Blackledge, Halifax HX1 1AF Email