Ormskirk Youth Day

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Ormskirk Youth Day

Name of Attendee *

Email Address *

Date of Birth *

YYYY

Gender *

Male

Female

Home Address *

Attendee Phone Number *

Ecclesia *

Baptised? *

yes

If Baptised willing to do a prayer or reading.

Transport Arrangements *

bringing own car

dropped off at Hall

Public transport. We can pick up from Ormskirk station

Lunch Requirements *

Fish and Chips

Sausage and Chips

Chips

Bring my own

Emergency Contact Name *

Emergency Contact Phone Number *

Parents Email *

Medical Information

Whilst on Ormskirk youth day we have a duty of care towards all children attending. We have a legal responsibility to collate medical information and parental consent to ensure we can respond quickly and efficiently to any emergency that may arise. Please could you therefore complete this information.

GP Details *

Dietary Requirements (please leave blank if none)

Medical History

eg. Asthma, Epilepsy or other allergies. Please leave blank if none.

Medication required on the day

e.g Inhaler, Epipen

Medical Consent

Tick to confirm your consent to one of the following statements

UNDER 18 - My child is under 18 and I understand that if it becomes necessary for my child to receive medical treatment and I cannot be contacted to authorise this, I hereby give my consent to any necessary medical treatment, including treatment under general anaesthetic. I authorise a designated senior leader in charge of the day to sign any documentation required by the hospital authorities.

*OR*

OVER 18 - I am over 18 and I understand that if it becomes necessary for me to receive medical treatment and I am not able to authorise this, due to illness or injury, I hereby give my consent to any necessary medical treatment, including treatment under general anaesthetic. I authorise a designated senior leader in charge of the day to sign any documentation required by the hospital authorities.

I consent (Under 18)

I consent (Over 18)

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