Well Centre August Activities - BOOKING FORM
YOU MUST BOOK IN ADVANCE
Please complete and return this form to book your place.

Please tick the activities you would like to attend:

Photography / Graffiti / Bike riding
Horse riding / First aid
YOUNG PERSONS DETAILS
Full Name: / MALE / FEMALE
Date of Birth: / Age:
Mobile/SMS:
Email:
Address:
FIRST EMERGENCY CONTACT*
Parent/Carer's Name:
Telephone: / Mobile/SMS:
SECOND EMERGENCY CONTACT
Full Name:
Relationship to youth:
Telephone: / Mobile/SMS:

* Parents/carers please ensure you are contactable on these numbers during the event.

MEDICAL DETAILS
Medical Conditions: (inc. details of any activities you are not able to do for medical or other reasons)
Prescribed Medicines:
NB: Bring all required medicines and equipment with detailed instructions to event.
Disabilities:
Wheelchair User: / YES / NO
Allergies / Dietary Needs:
FURTHER DETAILS: Please give any further information or any details that you think might be useful to us e.g. fears/phobias, behaviour, special needs etc.
YOUR AGREEMENT
  • I undertake not to hold the Well Centre, Redthread or Herne Hill Group Practice responsible for compensation in respect of loss or damage to personal property, which I sustain during any events or activities.
  • I understand the importance of advising the Well Centre of any medical or special needs that may require particular attention in order to enable my full and safe participation in the event.
  • I will not attend activities or events if I am not in good health or have been in contact with an infectious disease within two weeks of the commencement of the activity or event.
  • If at any point during an event I require urgent medical treatment, I give permission to the medical authorities to administer such emergency treatment, including anaesthetic, as they consider necessary in the circumstances.
  • In regards to the photography workshop I understand that I have the right to withdraw my consent if I later change my mind (as explained in the information sheet).

Young Person’s Signature:
Date:
PARENT / CARERS CONSENT FORM
(for participants aged under 18yrs old)
  • I confirm that I accept the agreement as detailed above and consent to my son/daughter (named above) taking part in this event.
  • In regards to the photography workshop I understand that I have the right to withdraw my consent if I later change my mind as detailed in the information sheet.

Parent / Carers Signature:
NAME IN CAPITALS:
Date:
IMAGE CONSENT
The Well Centre, Redthread and Herne Hill Group Practice like to document their work, including events and activities. The images may be used for internal documents, marketing and press, including the internet.
Agreement:
  • I agree to my image being used by the Well Centre, Redthread and Herne Hill Group Practice for internal documents, marketing and media. I understand that image/s may be used for publicity literature, websites, television/radio transmissions or videos that seek to promote our work. I also understand that we will not receive any financial reward for the use of image(s).

Date:
Young Person’s Signature:
Parent / Carers Signature:
(for participants under 18yrs old)

Events–

Activity 1: Photography workshops

Activity 2: Graffiti workshops

 Activity 3: Bike riding & picnic

Activity 4: Horse riding

 Activity 5: First Aid Stick-It Workshop

When –

Activity 1: Tuesday 5th August, 11:30am - 3pm & Friday 8th August 11:30am - 2pm

Activity 2: Tuesday 12th, Wednesday 13th and Friday 15th August 10am – 2.30pm each day

Activity 3: Tuesday 19th August, 10am – 2pm

Activity 4: Friday 22nd August, 10am – 1.30pm

Activity 5: Thursday 28th August, 11am – 3pm

All young people will be met at The Well Centre and returned back with staff after each activity.

Please wear comfortable clothing and trainers for bike riding, horse riding and first aid.

Activities are run on a first come first served basis, please return your consent form as soon as possible to avoid disappointment. If we do not receive your consent form before the activity you will be unable to attend.

Youth Workers contact details are –
Charlotte Savyell: 07788 491 063, Claire Devlin: 07885 913 590 or Well Centre 020 8473 1584.

PLEASE COMPLETE AND RETURN TO YOUR YOUTH WORKER OR DROP IT INTO THE WELL CENTRE – 16 WELLFIELD RD, STREATHAM, SW16 2BP.

You will be contacted before the activity so we can confirm attendees on the day 