Parent /Guardian
This form is to be completed each time your child wants to attend youth club.
Email *
In order to book in for LYCC Youth Club sessions, you must complete the following booking form/health questionnaire each week. We require this information for the safety of all our members, staff and volunteers.

Provide answers that are true to the best of your knowledge.

Due to public health guidance and Government Guidelines, our Youth Clubs will operate with a reduction of numbers attending

If you have more than one child in the Youth Club, please fill out this form for each child.
Youth Club Member Full Name *
Please select your child's class/year from the list *
Has your child (or any member of your household) had symptoms of COVID-19 / been identified as a CLOSE CONTACT / been asked to self-isolate / or are awaiting results of a Covid-19 test / traveled abroad in the past 14 days ? *
- If you have answered YES, or if your child develops any symptoms of Covid-19 then your child should stay at home, they should not come to Youth Club, and you should contact your family GP by phone for further advice.

Please seek medical advice immediately if your child has any Covid symptoms including symptoms associated with the Delta variant - headache, sore throat and blocked or runny nose (however mild). Do NOT attend the group.

- If you have answered NO, you may book for the Youth Club session

- Make sure that your child gets familiarized with the appendix to the Code of Behaviour in relation to Covid-19.*
. What session would you like to book for? *
Summer Sessions - no hot food. Tuck shop may be open for certain events at the Centre *
Parent/Guardian Name *
Parent/Guardian phone number *
I have no reason to believe that my child has an infectious disease and I have followed all medical and public health guidance with respect to Covid-19
Date of declaration *
Leixlip Youth & Community Centre
Newtown House, Captain's Hill, Leixlip, Co. Kildare
Phone: (01) 624 7435 Email:

Data Protection Notice. Your personal data is being collected on this form in order to help prevent the spread of COVID-19 at Leixlip Youth & Community Centre facilities. Your personal data is being processed in accordance with Article 9(2)(i) of the General Data Protection Regulation, and Section 53 of the Data Protection Act 2018. The information you provide on this form will not be used for any other purpose and will be strictly confidential. *Your information will be stored securely on the Leixlip Youth and Community Centre Management System.

Leixlip Youth Premises Group CLG is a registered Charity - RCN 20024666
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