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Hoxton Hall May Half Term Sign Up
In order to ensure the safety of all of our participants this form must be completed fully by all parents/guardians. By filling out this form you give permission for the London Borough of Hackney Youth Service to collect and store personal data about me and the activities which I participate in for monitoring purposes. I understand the data will be held in line with the Data Protection Act 1998 and subsequent updates and amendments.
Please fill out one form per participant.
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Participant First Name
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Your answer
Participant Surname
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Your answer
Participant Age
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Your answer
Gender
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Male
Female
Date of Birth
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MM
/
DD
/
YYYY
May Half Term Workshop 11-19
YES
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May Half Term Workshop 7-10
YES
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Please give details of any participant medical condition or allergies that it would be useful for us to be aware of (e.g. diabetes, epilepsy, asthma, hay fever etc.)
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Your answer
Please give details of any special educational needs that it would be useful for us to be aware of
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Your answer
Parent/Guardian Information
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Your answer
Parent/Carer First Name
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Your answer
Surname
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Your answer
Mobile Number
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Your answer
Email Address
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Your answer
Postal Address Line 1
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Your answer
Postal Address Line 2
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Your answer
Postal Address Line 3
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Your answer
Borough
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Your answer
Post Code
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Your answer
I consent to the participant receiving emergency medical or surgical procedures if necessary
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Yes
No
Are they allowed to go home by themselves?
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Yes
No
Are they allowed to go out for lunch by themselves?
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Yes
No
As part of the project we might go out to the park or other locations (weather permitting) Are they allowed to go on these supervised trips?
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Yes
No
I consent to Hoxton Hall using images/video footage of the participant for promotional purposes, including flyers, posters, reports, press, media and to share this with any partnering organisations involved Hoxton Hall projects
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Yes
No
Would you like to hear more about Hoxton Hall's work
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Phone
Email
No Thanks
How did you hear about Hoxton Hall?
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Young Hackney
Hoxton Hall website
Word of Mouth
Friends
Local press
Are you happy for us to share your details with similar organisations
*
Yes
No
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