Please Use BLOCK LETTERS and Complete All Sections

OFFICIAL-SENSITIVE

SPORT & PHYSICAL ACTIVITY REGISTRATION & CONSENT FORM May Half Term 2017 Please use BLOCK LETTERS and complete all sections

URBAN ADVENTURE BASE - 150 BURDETT ROAD, MILE END PARK, E3 4JT. T: 020 7364 0925 All activities and sessions are led by appropriately qualified and competent staff with appropriate levels of supervision applied at all times. All necessary personal protective equipment is provided. It is recommended to bring a change of clothes and appropriate clothing and footwear. See Consent & Agreement section (page 2) for details of activities and tick appropriately to give consent to take part in activities.

Young Person Details

First Name(s) Surname / last name Gender Date of Birth Age Address Postcode Telephone (Mobile) Telephone (Home) Email

Asian/Asian British Black/Black British Mixed/Dual Heritage Ethnic group White Other Prefer not to say

Disability / long term health Visual impairment Hearing impairment Learning disability problem that limits daily activities? Physical disability Multiple disabilities Other. Please write below None Prefer not to say

Parent / Guardian & Emergency Contact – Please complete with numbers that will be answered in event of emergency

Title Relationship Full Name Address Postcode Telephone (Home) Telephone (Mobile)

Medical / dietary information or requirements – please provide any information that may have a bearing on how we work with this young person or that may require us to act urgently e.g. asthma, old injuries, allergies, behavioural and/or dietary requirements:

The young person has the ability to swim: NON-SWIMMER / WEAK / GOOD / STRONG The young person has an asthma inhaler, epi pen or other medication? If yes to medication, please provide spares and do you give YES / NO consent to staff to administer medication as per request? On an average week, does the child participate in at least 30 YES / NO minutes of moderate intensity exercise?

Consent and Agreements - please read the statements below and tick the boxes if you agree OFFICIAL-SENSITIVE Page 1 of 2 OFFICIAL-SENSITIVE

SPORT & PHYSICAL ACTIVITY REGISTRATION & CONSENT FORM May Half Term 2017 - Use of images of young people - London Borough of Tower Hamlets Sports & Physical Activity Service may take photographs or video recordings of children and young people at our events or activities. We may use these images in printed publications, as well as on our website and local media.

I give permission to use photographs/video in digital and printed publications and media

- Data Protection Statement - The information contained in this form will be stored in accordance with the Data Protection Act 1998 by in a secure electronic system. We may share your information with other council services and relevant agencies or organisations to help us identify any additional support you may require and to help you obtain that support. This information may include details of any disabilities and ethnicity.

I give permission for you to share my information with other council services and relevant agencies

I consent to (NAME OF YOUNG PERSON)______taking part in the following activities (please tick) as part of Tower Hamlets May Half Term Programme 2017.

BMX Track Sessions at Mile End BMX Track delivered by Tower Hamlets BMX Club & Access Sports - Tuesday 30th May – Friday 2nd June 2017 (5-7yrs) 10.45-12noon Tues 30th Weds 31st May Thurs 1st Fri 2nd June (8-10yrs) 12:30-13:45 Tues 30th Weds 31st May Thurs 1st Fri 2nd June (11yrs+) 14:00-15:15 Tues 30th Weds 31st May Thurs 1st Fri 2nd June

Mountain Biking Taster session at the Urban Adventure Base - Tuesday 30th May 10-13yrs 13:00-15:00 14-19yrs 14:00-16:00

Canoe & Kayak Course – Tuesday 30th, Wednesday 31st May & Friday 2nd June * Please note 3 day Course (8-19yrs) 14:00-17:00 - Tues 30th & Wed 31st May at the Urban Adventure Base and 11.00-18:00 – Fri 2nd June - Paddle Power Journey East London Loop starting/finishing at UAB

British Cycling Breeze Ride (Female) – Friday 2nd June Please email [email protected] for information regarding registration (13yrs+) Session A. 11:00-15:00 Session B. 16:00-18:00

Signed – I give consent for me/my son/daughter/ward to take part in the activities as detailed above. Young Person – if you are under 18 your parent/guardian must sign and give consent. Signature______Date______Parent/Guardian Signature______Date______Name______Relationship to young person______

*Completed form returned via email to: [email protected]

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