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Child / young person's details

Name

Address

Postcode

Telephone number

Date of Birth

Parent or carer's details

Name

Home address

Postcode

Telephone number

Email

Emergency contact details (if different to parent / carer's details)

Name

Address

Postcode

Telephone number

Email

Child's medical details

GP:

Address

Postcode

Telephone number

Email

Does your child have any medical conditions or requirements we need to be aware of? (inc. allergies, medical, disabilities, injuries, religious beliefs etc)

Do we need to provide any extra help for your child/young person so that they can participate?

Are there any activities that your child/young person cannot participate in?

Is there anything else we should know?

I agree to:

My child taking part in summer programme activities

BCP Council keeping a record of this form for health & safety reasons.

Any medical treatment that my child may need to be given in an emergency.

My child being filmed or photographed during the activity, with the possibility of these being used for publication/marketing purposes.

Print Name

Signature

I am happy for my child to make their own way home after the activity

Or I will be collecting my child from the activity

Thank you

Activity Consent Form