Impact Youth Registration Form
Name of young person *
Your answer
Gender *
School attended *
Your answer
Date of birth *
MM
/
DD
/
YYYY
House number/name *
Your answer
Street *
Your answer
Town/City *
Your answer
County *
Your answer
Postcode *
Your answer
Name of Parent(s) or Guardian(s) *
Your answer
Emergency contact number *
Your answer
Alternative contact number
Your answer
Name of Doctor *
Your answer
Doctor's contact number *
Your answer
Any medical conditions and medication
(e.g. asthma, diabetes, epilepsy)
Your answer
Anything else we might need to know
(e.g. special requirements or dietary needs)
Your answer
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 *
Required
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?
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?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service