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AC-TI-VATE CHURCHILL GARDENS PROJECT 2025
Contact Details:
Email - Ryan.denys@sportwestminster.org 
Mob - 07956 956167 
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Email *
First Name (Participant Details): *
Surname (Participant Details): *
Address (Full Postcode Only): *
Main Contact Number: *
Emergency Details - Full name: *
Emergency Details - Contact Number *
Gender *
Male
Female
Prefer not to say
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Date of Birth (Child): *
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Ethnicity: *
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1. Medical Information: *
Asthma
Diabetes
Epilepsy
Heart Condition
None
Any Other
Do you have?
2. If you selected 'ANY OTHER' please specify?
Does your child have a disability, special need, or medical condition? If YES, please specify? *
Does your child have any allergies? If YES, please specify? *
Do you give permission for your child to participate in the ACTI-VATE Project? *
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COVID-19 DECLARATION: I attest that my child: *
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PARENT / GUARDIAN CONSENT & DECLARATION:  
I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practising social distancing.
I further acknowledge that Sportwestminster/City of Westminster has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Sportwestminster/City of Westminster cannot guarantee that the participant will not become infected with the Coronavirus/Covid-19.
I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, of myself and others, including but not limited to Coaching staff and other young people and their families.
I voluntarily seek services provided by Sportwestminster/City of Westminster and acknowledge that there could be a risk of exposure to the Coronavirus/COVID-19.
I acknowledge that I must comply with all set procedures to reduce the spread while attending session.
I hereby agree to release Sportwestminster/City of Westminster and waive on behalf of myself, my heirs, and any personal representatives any causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of these organisations, or that may otherwise arise in any way in connection with any services received from Sportwestminster/City of Westminster.
I understand that this release discharges Sportwestminster/City of Westminster from any liability or claim that I, my heirs, or any personal representatives may have against these organisations with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to any services received from Sportwestminster/City of Westminster. This liability waiver and release extends to all owners, partners, and employees.
PARENT/GUARDIAN CONSENT.
We are committed through accredited, trained, competent staff to provide a safe learning environment, however, these sports do have some contact and injuries may occur through no negligence of our staff. We feel it is our responsibility to ensure the safety of the attendee and your responsibility to make sure they come well equipped for the activity, i.e. correct footwear, appropriate clothing, lunch and appropriate drinks for hydration, medication (if applicable). I acknowledge and accept that the Sportwestminster/City of Westminster shall not have any liability in respect with any loss or damage to property and give permission for my child to receive emergency medical treatment in my absence if deemed necessary. I have read and understood the information contained in the leaflet, and I am happy for information to be held about me for council-funded services for young people. I understand that photographs, audio and visual recordings of the participant engaged in Sportwestminster/City of Westminster activities may be used for promotional or other materials, such as websites, local and national media I hereby give irrevocable permission for this. I agree that the participant and I shall have no right to the recordings and all recordings belong to the Sportwestminster/City of Westminster. I understand that the information given may be kept on a computer database, which will be accessed by the Sportwestminster/City of Westminster. I confirm that I agree with the above declaration and the information on this form is complete and accurate to the best of my knowledge.Our data protection policy is in accordance with the GDPR Act 2018.

Do you acknowledge and agree with the above parent / guardian declaration *
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Please kindly specify the capacity in which you give consent to this form? *
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If you selected 'OTHER', please specify relationship to above named participant? *
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Date: *
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