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.

Participant First Name *
Your answer
Participant Surname *
Your answer
Participant Age *
Your answer
Gender *
Date of Birth *
MM
/
DD
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YYYY
May Half Term Workshop 11-19
May Half Term Workshop 7-10
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.) *
Your answer
Please give details of any special educational needs that it would be useful for us to be aware of *
Your answer
Parent/Guardian Information *
Your answer
Parent/Carer First Name *
Your answer
Surname *
Your answer
Mobile Number *
Your answer
Email Address *
Your answer
Postal Address Line 1 *
Your answer
Postal Address Line 2 *
Your answer
Postal Address Line 3 *
Your answer
Borough *
Your answer
Post Code *
Your answer
I consent to the participant receiving emergency medical or surgical procedures if necessary *
Are they allowed to go home by themselves? *
Are they allowed to go out for lunch by themselves? *
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? *
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 *
Would you like to hear more about Hoxton Hall's work *
How did you hear about Hoxton Hall? *
Are you happy for us to share your details with similar organisations *
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