Space Community Team

  Youth Club Registration Form

Please note that the personal information you supply on this form is for the use of the youth leaders at Youth Club and is not available to any other individuals or groups. This means that we will not disclose any details provided without your permission and they may only be used in connection with attendance at the youth club.

Details of Young Person

Name ____________________________________________ Date of Birth ____/____/_______ Address________________________________________________________________________ _____________________________________________________ Post Code ________________

Emergency Contact Details
In the event of an emergency relating to your son/daughter please provide the details of TWO people below whom we can contact. 

Emergency Contact 1- Parent or Guardian

Adult Emergency Contact Name __________________________________

Contact Telephone Number ______________________________________

E-Mail (Please see tick box on Page 2) _________________________________________________________

Emergency Contact 2-

Adult Emergency Contact Name __________________________________

Contact Telephone Number ______________________________________

Medical Information
Are there any medical conditions (i.e. allergies, epilepsy, asthma, diabetes, travel sickness etc.) which we should be aware of?

______________________________________________________________________________

______________________________________________________________________________

Please give any details of special dietary needs we should be aware of (e.g. food allergies)

________________________________________________________________________________

________________________________________________________________________________

Photo/video consent form

I give permission to take photographs and/or video of my child

I grant full rights to use the images resulting from the photography/video filming, and any reproductions or adaptations of the images for fundraising, publicity or other purposes to help achieve the group’s aims. This might include (but is not limited to), the right to use them in their printed and online publicity, social media, press releases and funding applications.        Children will not be identified by name in any publicity.                                                

Tick box          

 Parent/Guardian Consent Agreement

I agree to my son/daughter participating in youth club and the activities run by the team.

I understand that every care will be taken to ensure the health, safety and welfare of my child.

I realise and accept that in the event of my child’s behaviour adversely affecting the safety of the activity, the organisers reserve the right to ask for my child to be collected from the session or remove them from a session if required.

I consent to my personal details being held for the purposes of EMERGENCY CONTACT ONLY

Tick box  

Use of Email Address- I agree to my email address being used by the club to notify me of CLUB OPENING TIMES and EVENTS only.

Tick box           

Name ________________________ Signature _________________________ Date___/___/___