VIEWS: 6 PAGES: 2 POSTED ON: 2/25/2010
I GIVE PERMISSION FOR MY CHILD TO ATTEND THE ABOVE NAMED ORGANISATION. Full name of Young person ____________________________________________ Date of Birth _____/_____/_____ Address_____________________________________________________________ Postcode _______________________________ Email______________________________________________________________ Details of any regular medication, medical problem (e.g. asthma, epilepsy, diabetes, allergies, dietary needs, etc.) or disability which may affect normal activity:_____________________________________________________________ ___________________________________________________________________ Please state date of last anti-tetanus injection if known ____/____/____ With whom does your child live? _________________________________________ Tel. Number: Day: ______________________ Evening: _____________________ Name of additional contact (grandparent etc or other holding parental responsibility) ___________________________ Telephone number ________________________ If you do not have parental responsibility (e.g. you are a foster carer/grandparent etc) please give details of those with parental responsibility Names _____________________________________________________________ Address(es) _________________________________________________________ Telephone number(s) _________________________________________________ GP name & telephone number__________________________________________ Please continue overleaf I give permission for _______________________ to take part in the normal activities of this group. I understand that separate permission will be sought for certain activities, including swimming, and outings lasting longer than the normal meeting times of the group. I understand that while involved he/she will be under the control and care of the group leader and/or other leaders approved by the church leadership and that, while the staff in charge of the group will take all reasonable care of the young people, they cannot necessarily be held responsible for any loss, damage or injury suffered by my son/daughter during, or as a result of, the activity. In an emergency and/or if I am not contactable, I am willing for my child to receive necessary hospital or dental treatment including an anaesthetic YES NO (Please tick) Signed (parent/or adult with parental responsibility) ________________________________ NB: a carer can complete the information part. Only those with parental responsibility (e.g. this does not include a foster carer) can sign the consent. Notes: Sedgley Community Church has a Health and Safety policy and a Child Protection Policy. All our volunteers have been police checked. We may take photos from time to time for publicity purposes. If you do not want your son/daughter to be in any photographs, please inform us. Sedgley Community Church, Bilston Street, Sedgley, DY3 1JB Please tick one of the boxes below: I give permission for photos, videos, dvds to be taken I refuse permission for photos, videos, dvds to be taken Please state who will be collecting your child at the end of the club. If for any reason someone else has to collect your child then you must inform us in advance. If you do not give a name your child will be allowed to leave without an adult.
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