Personal Information Form Leicestershire 2012 v3 by 04t6jy

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									                   PERSONAL INFORMATION & MEDICAL FORM
We will share this form with outdoor residential providers and, where applicable, a
sub-contracted NCS delivery partner. Data will also be shared with Cabinet Office for
monitoring and evaluation purposes. This form must be read and signed by the parent
of the young person (or somebody with parental responsibility)

                                  Participant Details
Surname                                     Forename(s)
Date of Birth               Gender          School
Home address

Home Tel.                                     Mobile Tel.
Email address:

Parent/carer email address:
For monitoring purposes only: Do you receive free             YES           NO
school meals? Please tick YES or NO


                                Emergency Contacts
                        Emergency contact Emergency contact                 Doctor
                               1                   2
Name


Relationship to
young person

Telephone


Mobile




                            Kitting You Out – please tell us...
Your height                    Your weight                    Your shoe size

Are you able to swim 50 metres in light clothing?



                  Dietary requirements e.g. vegetarian, vegan, halal etc.




                                                                                     1
           Medical – do you, or have you, suffered from any of the following?
  Please answer each item with Y or N as honestly as you can, and add details in the
                                       box below.
Heart trouble, Angina, Raised blood          Epilepsy, fainting, migraine, or
pressure                                     severe head injury
Asthma, bronchitis, tuberculosis, or         Severe hearing impairment
other lung condition
Diabetes                                     Severe visual impairment
Nervous illness, depression, or              Bladder/urinary problems
other psychiatric condition
Food allergy e.g. nuts, dairy                Are you suffering from, or are you a
                                             carrier of any infectious diseases,
                                             or have you travelled from an area
                                             where you were exposed?
Other allergic reaction e.g. hayfever,       Have you been treated by a doctor
insect bite                                  or in hospital within the last 2 years
                                             for anything other than minor
                                             complaints?
History of broken bones, muscle              If female, do you know or suspect
tears or ligament damage                     that you are pregnant?
Stomach, digestive or abdominal              Are you over-due a tetanus
problem                                      injection?
Blood disorders                              Do you have any other diagnosed
                                             condition, or do you feel there is
                                             anything else we should know
                                             about you as a participant in
                                             National Citizen Service?


 Additional medical information – if you have answered Yes to any of the questions
                         above, please provide details here.




                     Continue on a separate sheet if necessary


           Are you taking medication? If so, please provide details below:

Name of medication:
Condition to be treated:
Dosage:
       Please ensure that you provide sufficient medication for the programme




                                                                                       2
  Consent –The young person and someone with parental responsibility must read and
                make sure that they understand each of these sections
                Personal Responsibility and Standards of Behaviour:

Every reasonable measure will be taken to ensure the safety of participants on NCS. All of the
staff and volunteers working with NCS teams will have an enhanced CRB check and will
adhere to agreed standards and procedures for child protection and safeguarding. Risk-
management assessments will be carried out on all venues where NCS participants will be
based, the activities they undertake and their travel. Clear standards of behaviour will be
agreed at the outset of the programme and all participants will be expected to adhere to these.

One of the aims of NCS is to develop participants’ confidence and independence as young
adults. In keeping with this aim, we will expect all NCS participants to commit to maintaining
agreed standards of behaviour and to help maintain their own safety and the safety of other
team members. There will be times during the programme when participants will not be under
direct adult supervision and we will expect them to take personal responsibility for their safe
and appropriate behaviour. The use of alcohol and illegal drugs together with any form of
bullying, intimidation or violent behaviour will not be permitted at any time on the programme.

I UNDERSTAND THAT NCS PARTICIPANTS ARE EXPECTED TO COMMIT TO
MAINTAINING AGREED STANDARDS OF BEHAVIOUR, AND TO TAKE INDIVIDUAL
RESPONSIBILITY FOR HELPING TO MAINTAIN THEIR OWN SAFETY AND THE
WELFARE OF OTHER PARTICIPANTS.
           Adventure Activities – Safety and Acknowledgement of Risk:

Adventure activities will be provided by experienced outdoor providers with appropriate safety
arrangements and licenses.

The risk of serious injury to participants is extremely small but it is not non-existent. We take a
great deal of care of participants’ safety. However, as in any adventure activity, there will be
some factors beyond our control. Participants will be briefed before every activity and are
expected to follow the safety procedures explained to them and to indicate if they are unsure
what is expected of them. Participants are never forced to do an activity and if any participant
has concerns they should make these known to their instructor. The level of risk associated
with programme activities is low, and probably no greater than that experienced by active
people in everyday life.

 I DECLARE THAT ALL MEDICAL AND ENROLMENT INFORMATION ON THESE FORMS
   IS TRUE, THAT I HAVE NOT WITHELD ANY RELEVANT INFORMATION, AND THAT I
   UNDERSTAND AND ACCEPT THE ABOVE SAFETY AND ACKNOWLEDGEMENT OF
                                RISK STATEMENT:
                        Person with Parental Responsibility:

     In signing for a participant who is under 18 you endorse the following statement:

 “I consent to the above named person participating and taking part in all activities. In
 the event of an emergency and staff being unable to contact me, I give permission for
  any medical treatment deemed necessary to maintain his/her wellbeing. If the above
named person behaves unacceptably and removal from the programmed is agreed to be
the best course of action, I agree to make arrangements for them to be returned home.”

Print name          ....................................................................................................................

Relationship to participant ............................................................................................

Signature           .....................................................................................................................
Date                .....................................................................................................................


                                                                                                                                            3
                               Consent for images/voices
In order to promote National Citizen Service and record young people’s achievements
on the programme, we will make still picture and video recordings of participants.
These may be used as part of local, regional or national publicity campaigns for a
maximum period of two years. They will only be used to portray participants in a
positive light. Participants have the right to withdraw their consent for the use of
image and voice recordings at any time.

Please sign to indicate your consent if you are happy to be included:

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


Do you have any other needs or requirements, or is there anything else that we might
need to be aware of?




Do you consider yourself to have a           YES                   NO
disability? Please tick YES or NO


            Faith (for monitoring purposes only – please tick one option)
Christian                       Muslim                      Don’t know
Buddhist                        Jewish                      Prefer not to say
Hindu                           Other
Sikh                            None


  Ethnicity (for monitoring purposes only – please tick the option that best describes
                                your ethnic background)
White British                    White & Black African        Any other Asian
                                                              background
Irish                            White & Asian                Black Caribbean
Traveller of Irish heritage      Any other mixed              Black African
                                 background
Gypsy/Roma                       Indian                       Any other Black
                                                              background
Any other white                  Pakistani                    Chinese
background
White & Black Caribbean          Bangladeshi                  Prefer not to say


Have you previously helped out or volunteered with a YES                 NO
local group, project or organisation? Please tick YES
or NO
If yes, roughly how many hours of volunteering have
you done in the past month?
briefly describe the activity or activities you have
been involved in

To take part in NCS you need to be available for 2 consecutive full-time weeks, plus 30

                                                                                         4
hours part time volunteering. Please tick all the blocks when you will be available to
take part.
2nd. – 13th. July                                      16th. – 27th. July

13th. - 24th. August



If you would like to join a team with a friend please add their name and school here –
we will do our best to allocate you to the same NCS team




If you know the sort of activity or project you would like to get involved in please write
it in here. Or you may have an interest or skill you would like to develop? It is not
essential to write anything in this box, but here at Connexions Leicester Shire we
want to ensure we listen to all those who want to be part of National Citizen Service
2012 and make it the best experience possible




                       If in a team with a friend please add their name and school here

Please give your completed form, in an envelope marked private and confidential, to
your personal adviser in school or post it/e-mail it to:
Abigail Kearley
Connexions Leicester Shire
2nd Floor, 6 Millstone Lane
Leicester LE1 5JN
akearley@connexions-leics.org
If you do e-mail it we will still require the paper copy to be sent through to ensure we
have a signature.
 to allocate you to the same NCS team like to join a team with a friend please add thel

What happens next?

We will send you a postcard to confirm you have a place, your team name, start date
and which staff will be working with you.
We will keep you up to date with news as we countdown towards our summer of
adventure.
We will invite you to meet your team before you go on residential, so you know who
you will be spending your time with!

IF YOU HAVE ANY WORRIES OR CONCERNS ABOUT ANYTHING TO DO WITH YOUR
NCS PROGRAMME PLEASE LET ME KNOW
Abigail Kearley

akearley@connexions-leics.org

NCS am                                     Thank you


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