TD1 Consent Form
In the event of an emergency, it is important that we have the necessary information about contact details and any medical condition that could affect the participation or treatment of the young person.  It is important that full and accurate information be given and that you notify us of any change in circumstances that might affect participation.

All information requested will be held in strict confidence and stored in line with GDPR guidelines further details can be found here Data Protection. We do not share personal information outwith the organisation without permission unless a Child Protection protection matter.

Please visit the below link to read our Child Protection & Safeguarding Policy, should you have any concerns please take note of the contact details below.
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Name of Participant *
Date of Birth *
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Gender
Home Address *
Phone number *
Email address
Alternative Telephone number for use in emergency *
Has the above named person had recent surgery or been in contact with any infectious or contagious diseases? Please give description. *
Has the named above any known allergies? (eg Medication or Food)
Is the above named person currently undergoing treatment by a Doctor please give details including medication?
Has the above named person any medical condition which a doctor should know about before carrying out treatment(eg Asthma)
Is there any activity in which the above named person may NOT participate? (eg swimming)
Is there any additional information we should have or know?  (ADHD, travel sickness, diet, diabetes, etc?)
Has the above named person received a tetanus injection within the last ten years?
I give my consent for my child to take part in the activities available through TD1 Youth Hub, which includes minibus/public transport, outings, visits and outdoor and indoor activities. *
Required
I give permission that photograph/video images may be taken and used for evaluation and advertising purposes by TD1? *
Required
I give permission for TD1 to contact my child/me through phone, email, text or social media
Insurance Information
Liability Insurance will meet claims resulting from accidental injury or damage to property if it is proved it was caused as a result of negligence on the part of TD1 or a TD1 employee. Participants wishing to obtain cover for personal accident and Third Party Liability are advised to contact an insurance company or broker. Participants will be liable should they be found to breach agreed rules
Parent/Guardian Declaration (For under 16s)
I have read the information issued concerning the activity and the statement of insurance.  I understand the nature of the activity/activities to be undertaken and consider my child fit to take part.  They do not suffer from any medical condition not stated above.  I hereby consent to the submission of the above named to emergency medical or surgical treatment including the administration of treatment considered necessary by the medical authorities present. I am happy with the data protection policy and understand TD1’s policy on data protection. I understand that should my child misbehave or act in a manner that causes damage or destruction that I am liable for these costs.

I have read and understood the above declaration. *
Parent/Guardian full Name *
Date of completion and signature *
MM
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DD
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Any further questions
If you have any further questions in regards to our organisation or the activities please contact us via:

TD1 Youth Hub Telephone Number = 01896 752 442 / 07970 554 260
Chief Executive, Douglas Ormston = douglas@td1.org.uk
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