Spring Term 2019 Hoxton Hall
In order to ensure the safety of all of our participants this form must be completed fully by all parents/guardians. By filling out this form you give permission for the London Borough of Hackney Youth Service to collect and store personal data about me and the activities which I participate in for monitoring purposes. I understand the data will be held in line with the Data Protection Act 1998 and subsequent updates and amendments.

Please fill out one form per participant.

Term dates
23rd April 2019 - 8th July 2019

Participant Information
Participant First name *
Your answer
Participant Surname *
Your answer
Participant Age *
Your answer
Gender
Date of Birth *
MM
/
DD
/
YYYY
Ethnicity *
Monday
Monday
Monday
Tuesday
Wednesday
Thursday
Thursday
Saturday
Saturday
Please give details of any participant medical condition or allergies that it would be useful for us to be aware of (e.g. diabetes, epilepsy, asthma, hay fever etc.)
Your answer
Please give details of any special educational needs that it would be useful for us to be aware of
Your answer
Parent/Guardian Information
Parent/Carer First Name *
Your answer
Surname *
Your answer
Mobile Number *
Your answer
Home Phone Number
Your answer
Email Address *
Your answer
Postal Address Line 1 *
Your answer
Postal Address Line 2
Your answer
Postal Address Line 3
Your answer
Borough *
Your answer
Postcode *
Your answer
I consent to the participant receiving emergency medical or surgical procedures if necessary *
Are they allowed to go home by themselves? *
I consent to Hoxton Hall using images/video footage of the participant for promotional purposes, including flyers, posters, reports, press, media and on its own website *
Would you like to hear more about Hoxton Hall's work
How did you hear about Hoxton Hall?
Are you happy for us to share your details with similar organisations
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