11-18's Consent Form
Please complete this form for each young person attending !Audacious Conference
Delegate name
Your answer
Date of Birth
MM
/
DD
/
YYYY
Gender
Home Address
Your answer
Postcode
Your answer
Parent/Guardian Full Name (to be contacted in an emergency)
Your answer
Relationship to Child
Your answer
Parent/Guardian's contact number
Your answer
Parent/Guardian's Email
Your answer
Name of Family Doctor
Your answer
Contact Number
Your answer
Doctor's address
Your answer
Medical History - Please tick any that apply
Please specify other illness or disability and/or dietary requirements
Your answer
I agree to the delegate named above taking part in the activities provided by !Audacious. I confirm to the best of my knowledge that the delegate named does not suffer from any medical condition other than those listed above. I consent that in the case of an emergency / or I am not contactable, I am willing for the delegate named above to receive the necessary medical treatment including anaesthetic. I understand that !Audacious accepts no responsibility for loss, damage or injury caused by or during attendance of !Audacious. I consent to any photo’s or media footage being taken of the delegate named above whilst taking part in !Audacious and understand that these may be used for future publicity. I consent to the delegate named above travelling by any form of public transport, minibus or motor vehicle driven by an !Audacious staff member during !Audacious. I agree for the Group Leader to sign a waiver form for the delegate named above to take part in activities at another venue.
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