Youth Personal & Emergency Details Form


PRIVACY STATEMENT

The information collected on this form will be treated in accordance with the principles of the General Data Protection Regulation 2016. It will be stored on a password protected data server, accessible only to Children and Young People's leaders and members of The Church Leadership Team.

The Church Leadership Team is the Data Controller for the purposes of GDPR.

By completing and signing this form, you will be giving consent for the information on this form to be used for general church purposes relating to the named child and to contact you in the event of that child being involved in an emergency. The information will not be used by WBBC for any other purposes and will not be made available to any third parties

You have the right, at anytime in the future, to ask to see any information held here by submitting a ‘Subject Access Request’ to the Church Life Coordinator. You also have the right to ask for information which you believe to be incorrect to be rectified.

If you are still unhappy you have the right to complain to the Information Commissioners Office.
Email address *
Additional email address
Full Name of Young Person *
Date of Birth *
MM
/
DD
/
YYYY
Address & Postcode *
Home telephone *
Parent/ Carer Contacts
For Each Parent/Carer, please include the following:
Name
Relationship
Phone Number
Email
Name and relationship of Parent/Carer 1 *
Name and relationship of Parent/Carer 2
Name and relationship of Parent/Carer 3
Name Of GP *
Surgery Address & Postcode *
Surgery Telephone *
Parental Permissions
Tick all that apply
Events
I give permission for my child to take part in the normal activities of Youth Lighthouse. I understand that while s/he will be under the care of Lighthouse leaders, in accordance with WBBC Safe to Grow Policy, the leaders cannot necessarily be held responsible for any loss, damage or injury suffered by my child as a result of the activity. These sessions may be held on or off the premises e.g. social events, Bible Studies
Clear selection
I give permission for my child to be driven to and from events held for members of Youth Lighthouse, this will be in accordance with WBBC Safe to Grow Policy.
Clear selection
Photographs (to comply with Data Protection 1998 stating that permission is required.)
I agree that photos can be taken for in-house usage by WBBC which will only be seen by friends of WBBC e.g. for prayer nights and sharing in our groups.
Clear selection
I agree that photos can be taken for use at WBBC but that they may be seen by community members e.g. display on inside and outside the church
Clear selection
I agree that photos can be used on the church website, in social media, in newspaper articles and for publicity.
Clear selection
I confirm that all the information given on this form is correct. If this should change I will provide updated information.
Current and Correct?
Clear selection
Communication with your child: No later than 9pm
Please indicate and provide the appropriate information if you are happy for us to use that method to communicate information with your child directly
Postal Mail
Clear selection
Email
Clear selection
Mobile Phone including texting
Clear selection
If so, what is the young person's email address?
If so, what is the young person's mobile number?
Any Details you wish to add regarding the above question
One to One Sessions
There may be opportunities for your child to meet one to one with a Lighthouse Leader (male to male, female to female) to chat, pray and support him/her as required. These sessions would be optional and voluntary. If you require further information about this please contact the Team Leader.
I agree my child may meet in a public place for one to one sessions.
Clear selection
I agree my child may be talked with by telephone.
Clear selection
I would like to be informed at least 24 hours before my child is to be contacted about a one to one session.
Clear selection
PLEASE PROVIDE THE FOLLOWING MEDICAL DETAILS, IN CASE MEDICAL TREATMENT IS REQUIRED AND YOU CAN’T BE CONTACTED
Please detail any special dietary requirements
Details of any health or medical condition, (e.g. asthma, epilepsy, diabetes, allergies etc) or disability that may affect normal activity:
Please provide details of any medication that may be required during sessions:
Declaration: If I can't be contacted in an emergency, I am willing for my child to receive necessary hospital or dental treatment including an anaesthetic.
By ticking the below box, you officially submit all of the above information. This box can only be ticked by those with parental responsibility (e.g. this does not include a foster carer)
Name of parent who submitted the form
If you do not have parental responsibility please give details of those with parental responsibility below
Please format the response as such:
Name
Address
Tel No:
Parental details (as indicated above)
Submit
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