Please note all activities are free of charge to the young carers, but we do ask that you arrange your own way to the meeting point (usually the The Den unless otherwise stated) and are able to arrange your own way home.
Your child’s name:Your child’s age:
Date of Birth:
Your child’s address:
Child’s GP / GP’s name:
GP’s surgery and address: / GP Phone number
If your Child has a mobile phone please provide the number:
VERY IMPORTANT
Email Address:
Emergency contacts- Please note it is vital that we can get hold of you at all times for the duration of activities, and that you provide at least 2 DIFFERENT contacts. If you do not provide 2 contacts then your child will NOT be able to take part. / Name:
Relationship to Young Carer:
(This is also the person who we contact if your child has a place) / Home telephone number:
Mobile number:
Name:
Relationship to Young Carer: / Home telephone number:
Mobile number:
Please answer ALL of the questions below:
Does your child have any medical conditions?Has your child incurred any recent injuries or illness which required medical attention?
Does your child suffer from travel sickness? / NO
NO
NO / YES (please detail):
Does your child take any medication or tablets? / NO / YES (please list):
IMPORTANT: If your child requires assistance in taking their medication then you must also fill in Page 7of this consent form.
Does your child have any medical, food or other allergies?
Is your child allergic to plasters? / NO
NO / YES (please list):
Does your child have any special needs? / NO / YES (please list):
Does your child have behaviour problems? / NO / YES (please list):
Does your child have a special diet or any food that they will not eat?
Are there any medical procedures that are prohibited because of family or religious beliefs?
Date of last anti-tetanus injection if known.
NHS NUMBER /
NO
/ YES (please describe e.g. Vegetarian, Halal, wheat-free etc)
YES (please detail)
______
______
Has your child previously been away from home with school on a residential trip?
Is there anything else we need to know to provide activities to your child safely? / NO
NO / YES (please detail):
MEDIA CONSENT- I give consent for photographs/video material to be taken of my child, which may be used in the promotion of Carers Trust Heart of England. If you dogive consent then please tick this box.
TRANSPORT:
PLEASE NOTE THAT TRANSPORT CAN ONLY BE PROVIDED FOR YOUNG CARERS WHO HAVE NO OTHER WAY OF GETTING TO OUR ACTIVITIES.
Last project year we spent over half of our activities budget on taxi’s for young carers. While we appreciate that people may have no other means of getting to the sessions and activities, we would like to ask that people ONLY use the taxi service as a last resort. A result of this expenditure is that we were not able to provide as many trips as we would have liked to and many young carers missed out on opportunities to have a break from their caring role.
If money is an issue we are more than happy to refund money spent on BUS travel for the young carers attending sessions upon receipt of a valid ticket.
Please ensure that if transport is an issue you tick the box, and give your reason, as from now on, unless there is an emergency, ONLY people who have ticked this box will get offered transport. Even then we cannot guarantee that it will be available as we have a set budget allocated for this on a monthly basis and unfortunately once it’s gone it’s gone.
Do you require transport in order to access our young carers’ activities?
YESNO
Reason for requiring transport (please explain):
Once you have answered ALL the above questions, and read the following information please sign below if you accept and wish to give permission for your child to take part in our activities.
Whilst every attempt has been made to ensure that your child is safe by all parties concerned, we cannot guarantee injuries will not occur. Therefore you need to be fully aware that in participating injuries could be likely. We complete risk assessments on all of our activities, and if you wish to see a copy then please contact a member of the young carers’ team.
We expect your child to listen to staff, and be aware of safety at all times. There must be no wandering off alone unless authorised by staff. Whilst every effort will be made by the project to ensure the safety of the Young Carers, we cannot be held responsible for (i) accidents to any young person, and (ii) loss or damage to their property, unless there is evidence of negligence. The young carers are expected to take full responsibility of looking after their own spending money (if taken or required) and any personal possessions such as mobile phones. If any such item is lost the Carers Trust Heart of Englandtakes and accepts no responsibility. I agree to explain and discuss all this with my child prior to the trip.
I understand that all Young Carers’ activities are non smoking, and no alcohol is permitted. Any Young Carer found with tobacco or alcohol will have them confiscated and may not be allowed on future trips.In hot weather, your child will be required and responsible for bringing and applying their own sunscreen and other protective items such as sunglasses and a hat.
Transport from the The Den to the activity destination and back is provided (unless otherwise stated), however it is your responsibility to ensure that your child arrives for the time stated and is collected from the Den on return. If we have not heard from you and you are running late we will only wait 5 minutes before departing, and if you call to inform us- the maximum time we can wait is 10 minutes as this is then unfair on the other young carers. On occasions we may not have access to a coach/ minibus or taxi driver, so a member of staff or a volunteer from Carers Trust Heart of England may use their own car for transportation. The appropriate legal requirements are upheld in order for this to take place. Occasionally, a Carers Trust Heart of England approved taxi company may also be used.
Please note that the return times stated may vary dependent on traffic or situations which are often out of staff control. If there is a considerable delay in returning your child to you, we will attempt to contact you, using the numbers you have given us on this form.
If you have a problem being at the agreed collection point, you must call us to let us know as soon as possible. If you are not at the agreed collection point, we will try all the contact numbers you have given us for one hour. After that, if we still cannot contact a suitable adult and your child is too young to be left unattended, we may leave your child in the temporary care of Social Services.
I give permission for (young carers’ name) to take part in the Carers Trust Heart of England- Young Carers’ Project activities, and travel on transport approved by theCarers Trust Heart of EnglandI have understood and answered all the questions/information on this form. I have given all the information that is needed to provide activities safely. If any of the answers I have given change, I will let the young carers’ staff know before letting my child take part. If my child fails to adhere to the rules and conduct of behaviour required by the Young Carers’ Project (if you are unsure of these expectations please contact a member of staff prior to the trip), I understand that they may be returned home early. In this event as their guardian I agree to cover any costs incurred in bringing them back.
If my child can no longer take part in the activity, I will give the young carers’ staff as much warning as I can so that another child can enjoy the activity. If you fail to inform us that your child is unable to take part once they have been allocated a space, you may be held responsible for any cost incurred.
In case of a Medical Emergency
I give consent for medical examination when necessary. I request that any operation/treatment or other measures considered necessary by a medical authority be performed, and I hereby give my permission for such operation or other measures to be carried out in an emergency. I also permit administration of a general or local anaesthetic if necessary.
Parent/ guardian’s name:
Parent/ guardian’s signature: Date:
If you have any questions or require assistance in completing this form please do not
hesitate to contact our Young Carers’ staff on 024 76632972.
Only fill in this sheet if your child will need our help to take medication when they are on an activity.We cannot give your child medicine or store their medicine unless you complete and sign this page.
What is your child’s condition or illness?What is the medication or tablet called?
What is the dose? (e.g. how many tablets or spoonfuls)
When does the dose need taking? / Dose 1
Dose 2
Dose 3
Dose 4
How is the dose taken? (e.g. swallowed)
Are there any special precautions we need to take?
Please list any possible side effects.
Do you want your child to keep the medication on them? /
YES
/NO, PLEASE STORE THE
MEDICATION SECURELY
Do you want your child to take the medicine themselves? /
YES
/ NO, PLEASE REMIND MY CHILDTO TAKE THE MEDICATION
Will the course of medication end during the activity? /
NO
/ YES, the course willend on this date:
What should be done in an emergency?
I understand that I must deliver the medicine personally to staff and I accept that this is a service which the Carers Trust Heart of Englandis not obliged to undertake. All medication must be in its original packaging with name and dosage as prescribed by a pharmacist.
Signed: Date:
Please return to:
ADMIN TEAM
Carers Trust Heart of England
6 Queen Victoria Road
Coventry
CV1 3JH
Data Protection: 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 sheets will be stored securely then destroyed.