Spring 2016

CONSENT FORM

Staff Initial - ______Payment Method Cash Paypal Cheque Bank Transfer

PARTICIPANT DETAILS – Print in BLOCK CAPITALS

Full Name: ______Date of Birth: D D/M M/19 Y Y Age ____

Address: ______Area ______

Town: ______POSTCODE ______

Home Phone:______Parent’s mobile: ______

Mobile: ______Gender: Male/Female (please circle)

Email: ______

Parent Email: ______

Faith/Religion(please circle):

Christian / Buddhist / Hindu / Jewish / Muslim / Sikh / Other / Prefer not to say / None

Ethnicity: (please tick one)

White British / Black Caribbean / Chinese
Irish / Black African
Any other White background / Any other Black background / Traveller of Irish heritage
White and Black Caribbean / Indian / Gypsy/Roma
White and Black African / Pakistani
White and Asian / Bangladeshi / Any other ethnic group
Any other Mixed background / Any other Asian background / Prefer not to say

What school / college / training unit does your child attend? ______

Year Group at School/College Year 11 / Year 12 / Other (please specify) ______

Is your child entitled to free school meals? Yes / No

EMERGENCY CONTACT DETAILS – COMPLETE IN FULL

WE NEED TO BE ABLE TO CONTACT THESE PEOPLE DURING THE PROGRAMME

Emergency Contact Name (1): ______

Relationship (eg. Mum, dad, etc) ______

Tel No: ______(day) ______(eve)

Emergency Contact Name (2): ______

Relationship (eg. Mum, dad, etc) ______

Tel No: ______(day) ______(eve)

MEDICAL HISTORY AND BACKGROUND INFORMATION

PLEASE ANSWER ALL QUESTIONS

Doctors Name
Doctors Telephone Number
Surgery Address
Please Circle / If YES, Give Details
(continue on separate sheet if required)
Is your child registered disabled? / Yes/ No
Do you CONSIDER your child to have a disability? / Yes/ No
If personal assistance is needed do you give consent for staff to assist your child with physical support? / Yes/ No
Does your child suffer from any medical conditions or illnesses? / Yes/ No
Is your child receiving medical treatment at present? / Yes/ No
Is your child allergic to anything? (Antibiotics e.g. penicillin, plasters, other medicines or any particular food) / Yes/ No
Does your child have a level of personal care that we may need to consider? / Yes/ No
Does your child have any specific requirements to enable full participation in the events e.g. wheelchair access, large print, interpreter? / Yes/ No
Does your child have any specific dietary requirements e.g. vegetarian, low cholesterol, gluten free, halal? / Yes/ No
If YES, Give Details
(continue on separate sheet if required)
Has your child ever been in trouble with the police? (history of offending) / Yes/ No
Does your child have a special needs statement? / Yes/ No
Is your child blind or partially sighted? / Yes/ No
Is your child deaf or hearing impaired? / Yes/ No
Is your child a wheelchair user or have mobility difficulties? / Yes/ No
Is your child on the autistic spectrum or have Asperger syndrome? / Yes/ No
Does your child have mental health difficulties? / Yes/ No
Does your child have a history of truancy? / Yes/ No
Are there any concerns around self-harm/ eating disorders/ anxiety or depression? / Yes/ No
Are there any issues around substance misuse? / Yes/ No
Is your child a parent? (including pregnant) / Yes/ No
Is your child a young carer? / Yes/ No
Have you ever been in Local Authority Care? / Yes/ No / Current? o

Swimming Ability (this will be used to help us understand their ability during water based activities) (Please circle)

Is your child able to swim? / YES / NO
Is your child able to swim 50 metres? / YES / NO
Is your child water confident in a pool? / YES / NO
Is your child confident in open water? / YES / NO
Is your child safety conscious in water? / YES / NO

Where did your child hear about NCS? Choose from one of the options (circle):

Facebook/twitter/ social media / Advert / Word of mouth / At school / college
Media article / programme / Through youth group / organisation (including WYC) / Other

Which wave would you like to sign up for? Please tick one option

WAVE / Personal Challenge
Adventure Residential / Team Challenge
Stay at Home / Social Action
Stay at Home / Expected Finish / TICK ONE
SPR 1 / North Wales
Depart: Friday 12th February – 6 PM
Return: Monday 15th February – 1 PM / Tuesday 16th –
Thursday 18th February
Times TBC / 30 hours over evenings and weekends, / Sunday13th March
SPR 2 / North Wales
Depart: Monday 15th February –10 AM
Return: Thursday 18th February – 1 PM / Friday 19th –
Saturday 20th February
Times TBC / 30 hours over evenings and weekends / Sunday 13th March

Friends I think may be interested

Full Name______Phone Number ______

Full Name______Phone Number ______

CONSENT AND PERMISSIONS

By signing below, I agree and understand that:

·  My child will attend and take part in the NCS programme run by Warrington Youth Club,

·  The fee for the programme is non-refundable once paid,

·  Information provided on this form can be used by WYC (and partner organisations, including but not limited to the NCS Trust) for the purposes of running and evaluation the programme,

·  Safety is a major concern; it can often only be maintained if my child adheres to the conditions laid down by members of the staff team. If he/she fails to follow instructions it could create a potentially dangerous situation for themselves and others. In this situation I am aware that the programme and the staff may find it necessary to transport my child home at their/my own expense.

I give consent for photos and filming to be taken by Warrington Youth Club for marketing or publicity purposes, including Social Media. YES / NO


Parent / Carer Name (PRINT): ______Relationship ______

Parent / Carer Signature: ______Date: ______

Participant Signature: ______Date: ______

Payment should be made when completing consent form to and is required to secure a place on the NCS programme with Warrington Youth Club. Please note that the £35 payment we seek is only a very minor contribution towards the significant overall cost. Unfortunately this is non-refundable once a place is allocated. If you are concerned that you may struggle to make this payment, please contact us to discuss payment plans.

Payment options:

·  Cash

·  Paypal –

·  Cheque made payable to Warrington Youth Club

·  Bank Transfer - Account 82121204

Sort Code 40-45-24

Office Use

Warrington Youth Club, the Peace Centre, Peace Drive, Great Sankey, WA5 1HQ

TEL: 01925 581 227 EMAIL: