New Lodge Arts - Consent Form
Under 18's (to be completed by Parent/Guardian)

TINYS BALLET with BRONA for Nursery -P2, Thursday's 3pm-3.50pm, North Queen Street Community Centre (The Recy)
Participant Personal Details
Please provide the details of your child below
Full Name of Child *
Date of Birth of Child *
Address *
Postcode *
Religion *
Please provide details of parent/guardian below
Full Name *
Relationship to Young Person *
Address (if different from above)
Home/Mobile Telephone Number *Please ensure you provide an accurate phone number as a member of staff will contact you to ensure you have completed this form* *
Emergency Contact Details
Please provide emergency contact details that are different to the parent guardian who can be contacted, if the parent/guardian is unavailable, details above
Name *
Relationship to young person *
Home/Mobile Telephone Number *
Address *
Participant Medical Details
Please provide any medical details of the young person below
Doctors Name *
Surgery *
Surgery Address *
Phone Number *
Does your child have any additional needs? *
If yes, please give details below
Does Your Child Have Any Allergies or Ongoing Illnesses? If yes give details below *
If yes, please give details below
Please tick boxes below to indicate how your child will arrive at the youth centre at the arranged times (please note that if this should change you will need to complete a new form): *
Please Provide The Details Of The Person/Persons Authorised To Collect Your Child. Please Provide Name & Contact Number
Health & Safety Statements
Please read the health and safety statements below and tick if you want to give permission for these
I give my consent for my child taking part in an activity/event facilitated by New Lodge Arts *
I give my consent for my child to participate on trips and activities at various venues accompanied by New Lodge Arts Staff/Volunteers *
I give my consent for the leader in charge to seek medical help from a trained person or professional body should my child be hurt or take ill during an Activity with New Lodge Arts *
I understand that a member of staff who suspects that a child in his/her care may have been abused or neglected has a duty to report this to the designated officer within the organisation who will contact social services. *
Ashton is committed to protection and respecting your child’s information. Ashton give assurances that: • Any processing of personal information relating to your child is carried in compliance with the General Data Protection Regulation (GDPR) and the Data Protection Act 2018 (DPA). • Any staff handling personal data are subject to a duty of confidentiality and comply with the obligations under the GDPR and DPA. • Appropriate technical and organisational security measures to ensure compliance with the GDPR and DPA. • The obligations under the GDPR and DPA are met in relation to allowing data subjects to exercise their rights under the legislation. • Report data breaches to the Information Commissioner (if legally required) within 72 hours and co-operate with the ICO as necessary. New Lodge Youth Centre is managed from our office at: Ashton Community Trust, 5 Churchill Street, Belfast BT15 2BP. If you have any questions in relation to this Privacy Notice or the personal information we have about your child please contact the Data Protection Representative for Ashton Community Trust: Ciara Rea on 02890 322289 Ext: 3118 or alternatively email at view our full Privacy Notice look on our website at *
I am aware and consent to staff members contacting my child where appropriate about the programme through official social media such as Facebook and Messenger *
I am aware and consent to a staff member who has a full drivers licence and have the appropriate insurance to transport my child when necessary to and from certain venues *
Safety Protocols with regards to COVID-19 • Staff must be informed of any underlying health conditions that young people have. If parents have any concerns about the health of their child please get in contact with us as soon as possible• Hand sanitiser must be used on entering the building (this will be provided)• Regular hand washing and hand sanitiser use will be encouraged• Social distancing will be used• Masks will be provided if needed• All attendances will be recorded for track and trace purposes• Outside spaces will be used as much as possible• Regular cleaning will be undertaken• Only visitors with specific pre-arranged visits will be seen in person, all other communication will be via phone, email and online• Numbers attending will be limited Young people cannot attend if:• They are displaying any symptoms of COVID-19 – currently a high temperature, new continuous cough, loss of taste or smell• They have been told to isolate by either Track & Trace or their doctor• They have recently been in contact with someone who has COVID-19• They are no willing or able to adhere to the social distancing and enhanced hygiene measures• They have recently returned from a trip outside Northern Ireland (excluding the Republic of Ireland). In which case we would ask them to take 7 days before returning to programme/activities *
Permission can only be given by the individual/s that has parental responsibility for the child. Parental responsibility is defined as: The natural Mother always has parental responsibility. The Natural father gains paternal responsibility: • If he’s married to the mother at the time of the child’s birth. • If he marries the mother after the child’s birth, he has parental responsibility if he lives in Northern Ireland at the time of the marriage. • An unmarried father has parental responsibility if he’s named, or becomes named, on the child’s birth certificate (from 15 April 2002).
By completing and submitting this form you are accepting responsibility that you have provided full and accurate information that is required as a parent/guardian of the young person. *
Name Of Parent/Guardian Completing Form * *
Date Form Completed *
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