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Converse Enrolment 2017/18
Name of Teenager *
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Date of Birth *
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Age (from September 2017) *
School
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Parent's / Guardian's mobile numbers *
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Email of a parent or guardian *
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Address
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If a parent/guardian is unavailable please name another contact and their relationship to the teen *
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That person's contact number *
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Details of any known conditions, allergies, etc (e.g. asthma, diabetes, epilepsy) and any medication being taken. (if none write no) *
Your answer
Any other special needs, requirements or directions that would be helpful for the leaders to know about?
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Do you consent to their picture/video being taken and used for church purposes? *
During the time your child will spend with us, photographs or video may be taken for general church purposes e.g. powerpoint during worship and for this we need your permission.
Do you consent to their picture/ video being taken and used on our website or Facebook? *
Do you consent to us contact you by email for the purpose of letting you know times and dates of events? *
I give permission for my child to leave the building at the end of Converse without adult supervision i.e. to be picked up outside or to walk home *
please write your name below if you agree with the following statement: I give permission for my child to attend 'converse' at Kirkpatrick Memorial Presbyterian Church and to participate in all the activities. In the event of illness or accident, having parental responsibility for the above named child, I give permission for first aid to be administered where considered necessary by a trained first aider, if available, or medical treatment to be administered by a suitably qualified medical practitioner. If I cannot be contacted and my child should require emergency hospital treatment, I authorise an adult leader to sign on my behalf any written form of consent required by the hospital. However, I understand that every effort will be made to contact me as soon as possible. *
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