Impact Youth Registration Form

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Name of young person *

Gender *

Male

Female

School attended *

Date of birth *

YYYY

House number/name *

Street *

Town/City *

County *

Postcode *

Name of Parent(s) or Guardian(s) *

Emergency contact number *

Alternative contact number

Name of Doctor *

Doctor's contact number *

Any medical conditions and medication

(e.g. asthma, diabetes, epilepsy)

Anything else we might need to know

(e.g. special requirements or dietary needs)

I confirm that I have parental responsibility for the above named young person and In the event of illness or an accident, I give permission for first aid to be administered when necessary by a trained first-aider, or by a suitably qualified medial practitioner *

I give permission

I do not give permission

I will keep West End Impact up to date with any changes to these details regarding health or medication *

I agree

Required

During the summer term we may take the young people to the beach or the park behind West End Impact, do you give your permission for this to happen?

Yes

Clear selection

Are you happy for us to use photographs of the above named young person taking part in activities at West End Impact on our website and social media pages?

Yes

Clear selection

Submit

Clear form

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