NCS Parental Consent Form Feb 2018
Young Person Personal Details
First Name *
Your answer
Surname *
Your answer
Date of Birth *
DD/MM/YYYY
Your answer
Address *
Your answer
Postcode *
Your answer
Home Telephone Number *
Your answer
Young Person's Mobile Number *
Your answer
Young Person's Email Address *
Your answer
Gender *
If you answered Transgender to the above question please give details below
Your answer
Faith/Religion *
Ethnicity *
Name of school or college your child attends? *
Please include current Year Group
Your answer
Is your child entitled to free school meals *
Emergency Contact FULL Name (1) *
We need to be able to contact these people during the programme
Your answer
Relationship to young person (1) *
Your answer
Emergency Contact (1) Daytime Telephone Number *
Your answer
Emergency Contact (1) Evening Telephone Number *
Your answer
Parents Email *
Your answer
Emergency Contact FULL Name (2) *
We need to be able to contact these people during the programme
Your answer
Relationship to young person (2) *
Your answer
Emergency Contact (2) Daytime Telephone Number *
Your answer
Emergency Contact (2) Evening Telephone Number *
Your answer
Parents Email *
Your answer
Medical History - Childs Information
Doctors Name *
Your answer
Doctors Telephone Number *
Your answer
Surgery Address *
Your answer
Is you child registered disabled? *
Do you consider your child to have a disability? *
If you have answered YES to the above question please give details
Your answer
Does your child suffer from any medical conditions or illnesses? *
Please include any infectious dieases
If you have answered YES to the above question please give details
including dosage, time taken, any limitations etc
Your answer
Is your child receiving medical treatment at present? *
Including prescribed/non prescribed
If you have answered YES to the above question please give details
including dosage, time taken, any limitations etc
Your answer
Has your child had an injury in the last 2 years that required medical attention? *
If you have answered YES to the above question please give details
Your answer
Is your child going to bring any pain medication with them? *
including paracetamol, ibuprofen etc
Is your child Allergic to anything? *
Antibiotics, plasters, penicillin, other medicines, particular food
If you have answered YES to the above question please give details
Your answer
Does your child have a level of personal care that we may need to consider? *
If you have answered YES to the above question please give details
Your answer
Does your child have any specific requirements to enable full participation in the events? *
e.g. Wheelchair access, large print, interpreter?
If you have answered YES to the above question please give details
Your answer
Does your child have any specific dietary requirements? *
e.g. vegetarian, low cholesterol, gluten free, halal
If you have answered YES to the above question please give details
Your answer
Please answer Yes/No for the following *
Yes
No
Has your child ever been in trouble with the police (history of offending)?
Does your child have a special needs statement?
Is your child blind or partially sighted?
Is your child deaf or hearing impaired?
Is your child a wheelchair user or have mobility difficulties?
Is your child on the autistic spectrum or has Aspergers syndrome?
Does your child have mental health difficulties
Does your child have a history of truancy?
Are there any concerns around self harm/eating disorders/anxiety or depressions?
Are there any issues around substance misuse?
Is your child a parent (including pregnant)?
Is your child a young carer?
Are you in or recently been in local authority care?
If you have answered YES to the above question please give details
Your answer
Swimming ability
Swimming ability *
This will be used to help us understand their ability during water based activities
Yes
No
Is your child able to swim 50 meters?
Is your child confident in open water?
Where did you hear about NCS? *
Wave preference
There are limited spaces on each wave and these spaces will be given at a first come first serve basis.
*****Your place is not confirmed until you have paid £50. *****
Please indicate your preferred start date - please note this is a preferred choice and does not guarantee that you will be placed on this wave. *
Times and dates are arranged so that you won't miss any school/college. If you think you may, please contact us and we can clarify.
Please leave details of any friends that my be interested.
Full name, Phone Number, Email
Your answer
Parental Consent Agreement
Please the read the points below carefully.
Please read the statements below and indicate Yes or No *
Yes
No
I give permission for photos and filming to be used for marketing or publicity purposes, including WYC Social Media
I understand that the fee for the programme (£50) is non refundable once paid
I understand that whilst safety is a major concern, it can often only be maintained if my child adheres to the conditions laid down by members of the staff team.  Therefore, if he/she fails to adhere to such instructions it could create a potentially dangerous situation for themselves and others, then I am aware that the programme and its staff may find it necessary to transport my child home at their/my own expense.
I understand that there are strictly no drugs or alcohol allowed on NCS and if my child is found with or suspected of having or have consumed drugs or alcohol they will be removed from the programme.
Consent information
Spoke to parents and gained consent *
Parents Full Name *
By completing your name in this box you are electronically signing this form
Your answer
Date *
DD/MM/YYYY
Your answer
Thank You for completing this form!
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