OFFICIAL-SENSITIVE

Sport & Physical Activity Registration & Consent Form

May Half Term 2017

Please use BLOCK LETTERS and complete all sections

URBAN ADVENTURE BASE - 150 BURDETT ROAD, MILE END PARK, E3 4JT. T: 020 7364 0925
All activities and sessions are led by appropriately qualified and competent staff with appropriate levels of supervision applied at all times. All necessary personal protective equipment is provided. It is recommended to bring a change of clothes and appropriate clothing and footwear. See Consent & Agreement section (page 2) for details of activities and tick appropriatelyto give consent to take part in activities.

Young Person Details

First Name(s)
Surname / last name
Gender / Date of Birth / Age
Address
Postcode
Telephone (Mobile) / Telephone (Home)
Email
Ethnic group / Asian/Asian British / Black/Black British / Mixed/Dual Heritage
White / Other / Prefer not to say
Disability / long term health problem that limits daily activities? / Visual impairment / Hearing impairment / Learning disability
Physical disability / Multiple disabilities / Other. Please write below
None / Prefer not to say

Parent / Guardian & Emergency Contact –Please complete with numbers that will be answered in event of emergency

Title / Relationship
Full Name
Address
Postcode
Telephone (Home) / Telephone (Mobile)

Medical / dietary information or requirements– please provide any information that may have a bearing on how we work with thisyoung person or that may require us to act urgently e.g. asthma, old injuries, allergies, behavioural and/or dietary requirements:

The young person has the ability to swim: / NON-SWIMMER / WEAK / GOOD / STRONG
The young person has an asthma inhaler, epi pen or other medication?
If yes to medication, please provide spares and do you give consent to staff to administer medication as per request? / YES / NO
On an average week, does the child participate in at least 30 minutes of moderate intensity exercise? / YES / NO

Consent and Agreements - please read the statements below and tick the boxes if you agree

-Use of images of young people - London Borough of Tower Hamlets Sports & Physical Activity Servicemay take photographs or video recordings of children and young people at our events or activities. We may use these images in printed publications, as well as on our website and local media.

I give permission to use photographs/video in digital and printed publications and media

-Data ProtectionStatement - The information contained in this form will be stored in accordance with the Data Protection Act 1998by in a secure electronic system. We may share your information with other council services and relevant agencies or organisations to help us identify any additional support you may require and to help you obtain that support. This information may include details of any disabilities and ethnicity.

I give permission for you to share my information with other council services and relevant agencies

I consent to (NAME OF YOUNG PERSON)______taking part in the following activities (please tick)as part of Tower Hamlets May Half Term Programme 2017.

BMX Track Sessions at Mile End BMX Track delivered by Tower Hamlets BMX Club & Access Sports- Tuesday 30th May – Friday 2nd June 2017
(5-7yrs) 10.45-12noon Tues 30th / Weds 31st May / Thurs 1st / Fri 2nd June
(8-10yrs) 12:30-13:45 Tues 30th / Weds 31st May / Thurs 1st / Fri 2nd June
(11yrs+) 14:00-15:15 Tues 30th / Weds 31st May / Thurs 1st / Fri 2nd June
Mountain Biking Taster session at the Urban Adventure Base - Tuesday 30thWednesday 31stMay
Tuesday 30th
10-13yrs 13:00-15:00 / 14-19yrs 14:00-16:00
Wednesday 31st
10-13yrs 13:00-15:00 / 14-19yrs 14:00-16:00
Canoe & Kayak Course – Tuesday 30th, Wednesday 31st May & Friday 2nd June * Please note 3 day Course
(8-19yrs) 14:00-17:00 - Tues 30th & Wed 31st May at the Urban Adventure Base and
11.00-18:00 – Fri 2nd June - Paddle Power Journey East London Loop starting/finishing at UAB
British Cycling Breeze Ride(Female) – Friday 2nd June
Please email for information regarding registration
(13yrs+) Session A. 11:00-15:00 / Session B. 16:00-18:00

Signed – I give consent for me/my son/daughter/ward to take part in the activities as detailed above.

Young Person – if you are under 18 your parent/guardian must sign and give consent.

Signature______Date______

Parent/Guardian

Signature______Date______

Name______Relationship to young person______

*Completed form returned via email to:

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