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Hurworth Youth Project
Health Information and Consent Form for Academic Year 2026/27 - Hurworth Youth Project is a project of Darlington Area Churches Youth Ministry (DACYM)
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Email *
First Name(s) of Child / Young Person *
Surname of Child / Young Person *
Date of Birth of Child / Young Person - (DD-MM-YYYY) *
Address of Child / Young Person (inc Postcode) *
School Year (2026/27) *
School Child / Young Person Attending (2026/27) *
Name of Parent / Guardian (who is completing this form) *
Relationship to Child / Young Person *
Address inc Postcode (if different from child)
Mobile Telephone Number of Parent / Guardian *
GP Practice Name
*
GP Practice Address *
GP Phone Number *
Please provide any information about your child’s health that you feel would be helpful for us to know - long term conditions, disabilities, additional needs, regular medication, currently receiving ongoing medical treatment or recently received medical treatment. Please provide details below

Does your child have any allergies or food intolerance's we should be aware of?  Please provide details below and also speak with a leader at the first session attended.
*
Required
If YES, please provide details...
Please provide details of any dietary needs we should be aware of (eg vegan, gluten free, vegetarian, religious)...

Do you consent that in an emergency, and if you are not contactable, for your child to receive emergency/hospital treatment, including anesthetic.

(A leader would always try to contact you in the first instance.)
*
Hurworth Youth Project (DACYM) may wish to use photographs of our Friday Night Hang-Out/7-UP Club, and associated activities, on our social media and publications.  Do you consent for your child to be included in photographs, please tick box
DATA PROTECTION STATEMENT: In respect of the data relating to your child, we can hold this information for ‘legitimate interest’ in order to keep your child safe whilst in our care. The personal details provided on this form will be used to contact you in case of an issue at the Friday Night Hang-Out/ 7-UP Club and/or to give you information about these and other related activities. Your data will not be shared externally unless a safeguarding issue/medical emergency arises - and then only to the relevant authorities. Your data will be kept securely. A secure database will also be created to assist with communications. You can opt out of any mailings/text messages by contacting dacym@dacym.co.uk but please note we do need the essential data to safeguard your child.  If you have any queries relating to the information we hold and how we us it, please contact Martin Stand.

By ticking the relevant box you consent for HYP/DACYM to contact you by mail, email and/or text (inc WhatsApp)
Mail
Email
Text / WhatsApp
Contact Preferences

I confirm that the details I have given are correct, and I am entitled to make these declarations. 

I understand that Friday Night Hang-Out/7-UP Club has a Christian ethos. I give permission for my child to participate in the Friday Night Hang-Out/7-UP Club.

I understand that those attending the Hang-Out and the 7-UP Club remain on the premises for the duration of the session, unless specific consent has been given for the child/young person for them to leave.

I am aware that there is a behavioural code of conduct, which if consistently broken will result in my child being excluded from the Hang-Out/7-UP Club.

I am aware that HYP / DACYM has a child protection policy in accordance with Government good practice and will liaise with relevant authorities (Police/Social Services/Schools) to share concerns where appropriate.

I understand this form is valid until 31st December 2027, and if there are any amendments to this information after having returned this form, I will provide written details to DACYM.

I certify that my child is not receiving any other medical attention or taking medicines (except as already stated on this form) and is physically fit and able to take part in general HYP / DACYM activities.
*
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