Young Carers and Mentoring Support - Luton

Consent Form Young Carers and Mentoring Support - Luton

Name ______Gender : M F Date of Birth ______

We are required to seek parental consent for a child or young person taking part in our CHUMS Services. If you are 16 or over you may self-consent. As part of the service children and young people will be invited to participate in a variety of activities such as school sessions during school hours, after school sessions, weekly drop-ins, activity days and residential trips. Children/young people will also have access to one to one mentoring support, provided by trained CHUMS volunteers under the supervision of the project coordinator.

We would like to make you aware that CHUMS Recreational Service may also be working with external agencies to help provide this service and by signing consent you are giving your permission for us to contact the agencies on your behalf if appropriate.

We are committed to making sure that we regularly monitor and evaluate the support we offer. We therefore ask you to complete various questionnaires. These enable us to monitor how well we are doing in supporting your child and family, but also enable us to compare our results with other similar services across the country. Your personal details and all relevant information will be handled securely (no unauthorized person can see it). To make sure we have an overall idea of how you/your child is doing, with your consent, we will ask a member of school staff to fill out a ‘Strengths and Difficulties Questionnaire’.

I give permission to ask a teacher or member of school staff to complete the forms. Y N

Name of teacher who has most contact with your child:

Name and address of School

I consent to my child receiving complimentary therapy session whilst attending young carers and mentoring workshops and activity days at CHUMS. Y N

I hereby confirm that I have parental responsibility for the child named above and give consent for support by CHUMS services through group work or 1:1 sessions. I understand that my consent can be withdrawn at any time.

Parent / Carer Signature: Date:

Young Person’s Signature: Date:

Please provide us with any relevant medical information or allergies: ______Name and number for contact in case of an emergency: ______

Please talk to the person working with you, at any time, if you have any queries or concerns about giving your consent or the support you are receiving.