Shirley Youth Weekend Booking Form
Dates: 27 - 29th September 2019 (day visitors welcome £1 Fri, £12 Sat, £2 Sun + we still need a form)

Cost: £15 by 13th Sept to qualify for early booking reward 🍫🍬! (If the cost is putting you off, please get in touch)

Age: 14+

Ben Dwyer is speaking on "How Jesus Read the Bible".

Activities include, sports hall, volleyball, crafts, bouncy castle, camp fire...

Our legendary food continues with Chinese noodle boxes, Domino's and a roast dinner!

Sort Code : 60-19-14, Account Number 29498686 Reference. Attendee's Name

Get in touch for legacy payment options.
Email address *
Name of Attendee *
Your answer
Date of Birth - Day *
Date of Birth - Month *
Date of Birth - Year *
Gender *
Day visitor? *
£1 for Friday, £12 for Saturday, £2 for Sunday
Required
Home Address *
First line, postcode (all on one line)
Your answer
Attendee's Phone Number *
Your answer
Would you like accommodation for the weekend? *
Priority will be given to those who don't live locally
Accomodation Notes
If you are arranging you're own accommodation, who's it with? Can you accommodate people? Let us know any other details or uncertainties.
Your answer
Transport Arrangements *
Please select the relevant option and make any notes below
Transport Notes
Let us know any transport issues / details
Your answer
Emergency Contact's Name *
Your answer
Emergency Contact's Phone Number *
Your answer
Alternative Emergency Contact's Phone Number
Optional
Your answer
Attendee's Email Address
Please provide both attendee's and parent's email addresses if under 18
Your answer
Parents Email Address
Please provide both attendee's and parent's email addresses if under 18
Your answer
Baptised
Medical Information
Whilst on the Shirley Youth Weekend the leaders have a duty of care towards all children, a position which we take seriously. We have a legal responsibility to collate medical information and gain parental consents to ensure a fast and efficient response in a medical emergency. Please could you fill in this form as fully and as accurately as possible - Thank you.
GP's Details *
Your answer
Dietary Requirements
Leave BLANK if none. For food allergies, please specify whether you just avoid it as an ingredient or are sensitive to 'may contain traces' too. Also describe typical reaction - anaphylaxis, rash, swelling, vomiting, diarrhoea, gastric pain etc.
Your answer
Medical History
Leave BLANK if none. Please list full details of relevant medical history e.g. asthma, epilepsy, other allergies and investigations etc.
Your answer
Medication on the weekend
Leave BLANK if none. Please list all medication sent with attendee. Please include medication which is taken on a regular basis and those which are used as required i.e. inhalers, antihistamines or Epipen.
Your answer
Please ensure that children bring a sufficient dosage of their medication in a safely packed, clearly marked container. The marking should state the name of the person, the name of the medication, any storage requirements, and the frequency, quantity and method of administration.
Self Medication (Under 18s)
If your child normally self medicates and can be relied to do this responsibly on the weekend we need your consent for this. If this consent is not given, medication can be held and administered by a first aider. If a child is self-medicating, please send an additional emergency supply, to be held by leaders.
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 weekend 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 weekend to sign any documentation required by the hospital authorities.
*Note. The medical profession takes the view that parent’s consent to medical treatment cannot be delegated. This view is explicit in the Children Act 1989. Thus medical consent forms have no legal status and a doctor/nurse insisting on consent of a parent to a particular treatment has the right to do so. For this reason we do not recommend that leaders insist on parents signing the statement above. However, it can be a comfort to medical staff to have medical consent in advance from parents or have a leader on hand able to sign forms required by medical authorities.
Thanks for booking on. Now click submit
(if it doesn't take you to a confirmation page, there is still a question missing an answer)
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service