Holy Trinity, Rothwell

A place for everyone


Youth Group

(for 11-16 Year olds)

Revd Ruth Colby

Assistant Curate, Tresham Benefice

6a Kipton Close, Rothwell

NN14 6DR

revruthcolby@gmail.com

phone: 01536 770178








Tresham Benefice Youth Group

Registration and Consent form 2018.

This information will help us contact you should we need to, please complete the return to us:

Information about the Young Person


First name


Surname


Date of Birth


Address




Mobile number (if appropriate)


E-mail address (if appropriate)


Name of parents/ guardians



Family Doctor name


Address


Telephone


School


School Year


Any food allergies? (please specify)


Any medical conditions? (please specify)


Any medication including inhalers? (please specify)


Details of last anti-tetanus injection


Any special needs? (please specify)


Is there anything else you would like us to know about this young person?



Information about parents/guardians/carers


Parent/Guardian contact 1

1.

Name

2.

E-mail address


Telephone

Home:

Mobile:


Parent/Guardian contact 2

1.

Name

2.

E-mail address


Telephone

Home:

Mobile:

Alternative emergency contact details (if appropriate):


Contact name for carer/ an alternative adult in case of emergencies


Tel no


Relationship to the young person



Declaration

Section 1

I give permission for………………………. (young person) to attend and take part in the Youth Group programme including off site activities as outlined in the programme.

I consent to images of the young person named above being used and stored, for the purposes of publicity in Tresham Benefice publications and on the website. I understand that no names will be attached to online images, but First Names may appear in printed publications YES / NO (please delete as applicable)


I give permission that in the event of any accident/illness first aid treatment can be administered and, if needed, my child can be transported to hospital. I also understand that while the Youth Group leaders

will take every precaution to endeavour that accidents do not happen, they cannot be responsible for damage, injury or loss suffered by my child.


Signed (parent / guardian) ……………………………………………… Date………..........……………


Name (parent/guardian) …............................................................



The information requested on this form can be completed by a carer, but only those with

parental responsibility can sign the consent (N.B. this may not include a foster carer)



Section 2


I acknowledge that expensive personal possessions are my son/daughter’s responsibility and that leaders cannot be held responsible for any loss or damage to my child’s property.


I understand that if my son or daughter grossly misbehaves at any group or activity the leaders may forbid them from continuing to take part and they may be asked to leave/ be collected by their parents or guardians. I agree to pay for any deliberate damage caused by my son/daughter.


I give permission for Tresham Benefice to process the information given on this form and hold it on a database, for use by Tresham Benefice only. The information held will not be passed to any other party.

Signed (parent/guardian) …............................................................ Date ….......................

Name (parent/guardian) …............................................................









  • Squires Hill
  • Rothwell, Kettering
  • Northamptonshire
  • NN14 6BQ


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