Impact Youth Registration Form
Name of young person *
Gender *
School attended *
Date of birth *
House number/name *
Street *
Town/City *
County *
Postcode *
Name of Parent(s) or Guardian(s) *
Emergency contact number *
Alternative contact number
Name of Doctor *
Doctor's contact number *
Any medical conditions and medication
(e.g. asthma, diabetes, epilepsy)
Anything else we might need to know
(e.g. special requirements or dietary needs)
I confirm that I have parental responsibility for the above named young person and In the event of illness or an accident, I give permission for first aid to be administered when necessary by a trained first-aider, or by a suitably qualified medial practitioner *
I will keep West End Impact up to date with any changes to these details regarding health or medication *
During the summer term we may take the young people to the beach or the park behind West End Impact, do you give your permission for this to happen?
Clear selection
Are you happy for us to use photographs of the above named young person taking part in activities at West End Impact on our website and social media pages?
Clear selection
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