Halifax Youth Weekend 19th - 21st January 2018
Booking & consent form
First name *
Your answer
Last name *
Your answer
Date of birth *
Your answer
Address *
Your answer
Postcode *
Your answer
Youth Weekender's mobile number *
Your answer
Youth Weekender's home number *
Your answer
Youth Weekender's Email *
Your answer
Parent's name(s)
Your answer
Parent's email
Your answer
Ecclesia / Youth Group
Your answer
Baptised *
Booking type *
How will you be traveling *
If arriving by train please state which station and the time you will arrive at
Your answer
Are there any friends you would like to stay with? We will do our best to accommodate this.
Your answer
Do you have any dietary requirements (vegetarian, food allergies / intolerances etc...)
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Emergency Contact 1 - name and telephone number *
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Emergency Contact 2 - name and telephone number
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Name of GP *
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Address of GP *
Your answer
Telephone number of GP *
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Please give details of any health or medical conditions (e.g . Asthma, Diabetes, Epilepsy) *
Your answer
Please give details of any allergies *
Your answer
Please give details of any regular medication. *
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Will medication be required during the weekend *
Date of last tetanus immunisation *
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MEDICAL CONSENT - for anyone under 18 this must be completed by their parent / guardian. Over 18's may consent themselves. In the event of an emergency I agree to my child (under 18's) / me (over 18's) being given medical, surgical or dental treatment, including general anaesthetic and blood transfusion, as considered necessary by the medical authorities present. *
Under 18's - parental consent - I agree to my child taking part in all the activities of Halifax Youth Weekend and to him / her being transported by hosts and youth leaders as necessary. I understand that my child will need to adhere to any guidance and instructions given throughout the weekend to ensure their safety and well-being. I have discussed this requirement with him / her. *
Required
Over 18's - self consent - I agree to take part in all the activities at Halifax Youth Weekend and to and being transported by hosts and youth leaders as necessary. I understand that I will need to adhere to any guidance and instructions given throughout the weekend to ensure my safety and well-being. *
Required
Anything else you wish the Youth Weekend Leaders to know?
Your answer
You will receive confirmation of booking once payment has been received. Please see poster for details of payment or email gill.holden@blueyonder.co.uk *
Thank you for booking on Halifax Youth Weekend we look forward to welcoming you in January, God willing.
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