PARENTAL AGREEMENT FORM
1.Youth Centre/Project: The Hub Youth Centre & Voice Project
2. Activity: 17/02/17 – 12 - 4.30pm OXYGEN FREEJUMPING & PIZZA 15/02/17 – 10.30am – 2pm BOWLING
Please tick box for trip/s you would like to attend
Please bring: Plenty of drinking water & suitable clothing for trampoline park & bowling
3. Location: Oxygen Acton, 15, Vision Industrial Park, Kendal Avenue, London W3 0AF
Date: SEE ABOVE Cost: FREE
4. Youth Worker in Charge: Kuldip Sandhu – 07939 314220
5. Full name of Young Person:______
Date of Birth:______Age______
Gender: Male/Female (please delete) Ethnic Origin:______
6. Home Address:______
______Postcode: ______
Tel No:______Emergency Tel No:______
I, the parent/guardian of the Young Person named above
1. hereby give permission for the Young Person to take part in the activity detailed above. I understand that any changes to the itinerary, travel arrangements etc. will be notified to me as soon as possible;
2. note that neither the Council nor the youth worker named above are liable for any claim or claims of whatsoever nature arising during the activity referred to above and by virtue of the attendance of the Young Person, except incidents arising from the negligence of the Council or its servants;
3. warrant that the information given (overleaf) is correct to the best of my knowledge;
4. agree that the youth worker named above may act on my behalf in all matters affecting or concerning the Young Person. I understand that all reasonable efforts will be made to contact me before taking action, but in particular cases this may not be possible. Upon contact I, the parent/guardian, will make every effort to respond to the Council's request;
5. agree to the Council making any further enquiries considered necessary as a result of the medical information given overleaf, to establish whether the Young Person is medically fit to participate in the activity. In the event of the Council deciding in its absolute discretion, that the Young Person is not medically fit to participate, I understand that any sum paid by me in respect of any costs or expenses of the journey will be refunded to me in full, (less a deduction covering administration expenses and deposit).
Please note, that from time to time, photographs and video may be taken of activities for publicity, monitoring and recording purposes.
Please tick this box if you do not wish for your child’s image to be reproduced. Details of illness or hospital treatment
Please insert below details of any illness suffered or hospital treatment undergone by the Young Person within the past two years or any pre-existing medical condition. If there are none, please mark 'None'.
Date of illness or duration Nature of condition Name and address of Name and address of of stay in hospital or hospital doctor or surgeon. (approx. if necessary) type of illness (if appropriate)
Tetanus Has the Young Person named overleaf had an anti-tetanus injection within the past 10 years?
If Yes, please give approximate Date: ______
Infectious diseases
To the best of your knowledge, has the Young Person been in contact with anyone suffering from an Infectious disease during the past three weeks or has there been any infectious disease in the house during that time?
If Yes, please give details:______
Known allergies Please give below a list of any substances including drugs, foodstuff or other to which the Young Person has suffered an allergic reaction at any time. If the Young Person suffers from hayfever, please state ‘Hayfever’ below.
Asthma Does the Young Person suffer from asthma? Yes No If Yes,
a) Is the condition stabilised?
b) Has your doctor given approval for this activity?
Medication If the Young Person requires any medication during the activity, it is the responsibility of the parent/ guardian to provide drugs in a suitable container, which is clearly labelled with the Young Person's name, the name of the drug and dosage to be taken. An adequate supply must be provided to cover the whole of the activity, if necessary. Please write here the details of medication and dosage.
Please give the name, address and telephone number of the Young Person's General Practitioner.
Dr:______Tel. No:______
Address:______
Please give the Young Person's medical number (as shown on the Medical Record Card):______
The Young Person can swim 50 metres unaided
Does you child have any learning difficulties or physical disabilities?______
Do they have any behavioural needs/ challenging behaviours?______
Do they have any phobias?______
Are there any triggers or any other issues that might affect them during the activity?______
I fully understand the nature of the activities involved Signed:______(Parent / Guardian) Date:______Parent/Guardian’ Date Of Birth:______(The above information is correct and completed to the best of my knowledge)