REGISTRATION & CONSENT FORM
‘WHAT IS REAL BEAUTY’ GIRLS CONFERENCE
1st June 2016, 11am-2.00pm
This form should be completed by a parent/guardian if you are under 18, before you are able to participate in any activities with PHOEBE. If you are over 18 you should complete the form yourself and sign at the end of the second page. Anything written on this form will be held in confidence.
Child/Young Person Information
Full name of child/young person
Date of birth
Home Address
Postcode
Telephone numbers:
Home Young person’s mobile
Parent/Guardian Information
Name of Parent/Guardian young person normally lives with
Telephone numbers:
Day Parent/Guardian’s mobile(s):
Re: collection of children from our Organisation: is there any person we should know about who has restricted access to your child/children? Yes / No (delete as applicable). If yes, please state with details.
Emergency Contact Details
We would appreciate an alternative contact name and details in case of an emergency.
Contact Name
Telephone
Child/Young Persons Medical Details
Please supply details of any regular medication, medical problem or disability that may affect regular activity
Is your son/daughter allergic to or sensitive to any food/medication? E.g. penicillin, plasters, fizzy drinks. If so could you tell us the effects they have?
Has your son/daughter received a tetanus injection in the last ten years? Yes / No
Please state if your child/young person would like to perform/share something? Yes / No
(e.g. singing, dancing, musical instrument)
Lunch: A wide range of pizza's of your choice!
Please Tick which pizza you would like.
Allergies- (may contain SOYA and CELERY)
*Cheese and Tomato (V)
*Garden party- Red onions, green peppers, fresh tomato, sweet corn and mushroom (V)
*Double Pepperoni and cheese
*Chicken club- Char grilled chicken, stacks of bacon, sliced onion and fresh tomato
*Premium Hawaiian -Ham and pineapple
*Tandoori spice- Tandoori chicken, green peppers, red onion, fresh tomato
*The Greek- Crumbled feta cheese, red onion, tomato, black olive, sliced pepperoni, mozzarella and oregano
(Contains gluten, wheat and milk)
Facilitated by Tender, the Conference will use Theatres & Arts to engage the girls to learn about how to be good friends, coping when friends exclude you, coping with bullying and cyber bullying. The girls will be completing a scrapbook related to this. Please choose an option below.
- I plan to bring my own scrapbook.
- I plan to buy the scrapbook provided by PHOEBE for £5.
‘Lush’ will be offer short appointments for skincare advice and product sampling in the afternoon – please contact us on 01473 231566 to book an appointment.
Are you happy for photographs/film to be taken of your child/young person? Yes / No
Declaration
- I understand that this consent form covers my child to take part in the self-esteem conference that is delivered by PHOEBE. In an emergency and/or I am not contactable, I am willing for my child to receive emergency dental, medical or surgical treatment including an anaesthetic, which is considered necessary by a medical authority.
- I will inform a staff member at PHOEBE of any changes in any of the information requested on this form.
- I ensure that my daughter understands that it is important for her safety and the safety of the group as a whole, that any instruction given by staff in charge, are obeyed.
- I understand that while PHOEBE staffs are in charge, they will take all reasonable care of the young people, and unless they are negligent, cannot be held responsible for any loss, damage or injury suffered by any child/young person arising during the conference. I understand that young people are counted to be in the charge of PHOEBE staff from the time they arrive at Suffolk New College to the time that they leave the premises (for any reason, unless part of the conference), and that those running the PHOEBE self-esteem conference are not responsible to see that children/young people arrive at the venue or arrive home after they have left.
Signed (parent/guardian)
Date