Litter Clean Up Approval & Consent Form 2007-2008 by yn5404w


									                                 Cornwall Litter Partnership
                     Litter Clean Up Event Approval and Consent Form

This form is designed to enable the young person, parents or carers and the clean up organiser to share essential
information to make sure the health, safety and welfare of the young person has been considered. It also requires that the
young person, parents or carers have understood and agreed to abide by, the contents of the risk assessment for the event.

Event Date_________________________________ Event Location__________________________________________

Name of Organiser ____________________________                     Tel. No__________________________________________

Name of Young person ____________________________________


Post Code __________________________________                       Tel. No_____________________________________

Name of Contact_____________________________________ Emergency Contact Tel. No_______________

Essential information relevant to Health, Safety and Welfare
In order for the organisers to provide a safe event for young people it is essential that any medical or other significant
information that may affect your son/daughter’s health and safety is provided. Please complete the information below.

Does your son/daughter:-                                                                                      YES NO
Have any restrictions of normal physical activity? *
Have skin allergies or eczema? *
Have bronchitis, asthma or chest complaints? *
Have fainting attacks or fits? *
Have any hearing disability? *
Have any significant colour vision defect or other vision disability? *
Have any learning difficulty that may affect their ability to understand or act on instructions? *
*Please give any relevant details:-

Have any other health problems that may affect their safety and welfare, including the need for regular
medication? If so please outline the details:-

Have a specific disability and/or a Care Plan? If so please give brief details.

Any other information you would like to make the employer aware of that could affect the health, safety
and welfare of your son/daughter:-

Health and Personal Information
I agree that the above information can be seen by the Litter Clean Up organiser, who can disclose any information that they
feel is relevant to the health, safety and welfare of the young person in my care whilst on the event detailed.

I am aware that some or all of the information contained on this form may be stored either manually or electronically in
accordance with the Data Protection Act.

Signature of Parent/Carer________________________________________Date_________________

Signature of Event Organiser____________________________________Date__________________

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                                Cornwall Litter Partnership
                    Litter Clean Up Event Approval and Consent Form

Risk Assessment

Please read the specific risk assessment for the event noted above, that you should have received with this form (please
contact the event organiser if you have not received a copy of the risk assessment). By signing below you will agree that the
young person in your care will observe the contents of the risk assessment and any directions given by the organisers or
supervisors during the event. If conditions change this may require appropriate adjustments to be made to the risk
assessment on the day.

I have read and understood the risk assessment for the activity and consent to;

Insert name of young person here: ___________________________________________taking part in the above event.

Signature of Parent/Carer________________________________________Date_________________

Young person

I understand the contents of the risk assessment and the standards of behaviour that will be required of me and agree to
follow all instructions given by the event organisers or supervisors whether given as direct instructions, via training or
displayed material. I also agree to take reasonable care of my own health, safety and welfare and to take particular care of
anyone else who may be affected by my actions.

Signature of Young Person______________________________________Date__________________

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