Name of young person:

Address: / Post Code:
Tel No: / Mobile:
e-mail:

Date of Event 23rd July 2016Venue: Walberton, near Arundel

Please provide contact addresses and telephone numbers for emergency purposes of two responsible adults e.g. parent/guardian/relative

Name / Name
Address / Address
Tel (Home) / Tel (Home)
Tel (Work) / Tel (Work)
Tel (Mobile) / Tel (Mobile)
Is the young person allowed to return home on his/her own?
If no, who will collect them?(Please notify us if this changes)
Medical/Special Requirements:
Do they take regular medication?
Do they have a disability, allergy or special needs?
Do they require routine use of medication (eg inhaler)?
If slightly cut, may we apply a plaster?
Do they require a special diet? * if YES please provide additional information below.

Name & address of young person’s doctor:

Tel:

Date of last anti-tetanus injection: ______

Additional Information:

(If appropriate)

How did you find out about this event?

Data Protection Statement:

This information will be securely held by the Petworth & Bognor Angling Club, and will be used for administration purposes only. Details will not be sold or given to any third party. Please ensure that you inform us of any changes to this information.

While I appreciate that every attention will be given to personal safety, in the event of an accident, I permit the Petworth & Bognor Angling Club to authorise any medical treatment, which they believe necessary.

Signed: Parent/Guardian/Relative Date:

Photographic image / video consent

Photographer:Petworth &Bognor Angling Club

Location:Walberton Near Arundel

Date of event:

I give permission for the photograph(s) / videos taken to be stored on Petworth & Bognor Angling Clubs hard drive and used by Petworth & Bognor Angling Club within their communication materials (including publications, press and web) for non-commercial purposes; they will not be passed to third parties.

I understand that if the Petworth & Bognor Angling Club wishes to identify me individually, they will ask my permission first.

I am over 18 years of age

I am under 18 years of age

Signature of model/parent/guardian

Address of parent/guardian (if model under 18 and different from the above) ………………...

…………..…………………………………………………………………………………………………

…………..…………………………………………………………………………………………………

Name and Signature of witness………….…….………………………………………………………

 Parent/guardian signature is required for models that are under 18 years of age.

In accepting the above release, the Petworth & Bognor Angling Club undertakes that the copyright material shall be used in accordance with the terms of the release. Personal details will not be used for any other purpose than for this form.

Thank you for taking the time to complete the form. Please return it to the address below:

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Petworth & Bognor Angling ClubJunior Tuition / Taster Version 1:1