Tuesday Night Youth Club Consent Form:

Child’s name:
Date of Birth:
School:
Parent/Guardian name:
Contact number:
Emergency contact name:
Emergency contact number:
Signature:

How will your child get home from Youth Club?

Make their own way home:
Collected by parents/guardians:
Taxi service:

Do you give consent for your child to receive first aid treatment?

Yes:
No:

Does your child have any injuries or medical needs which we need to be made aware of?

Yes:
No:

Does your child have any allergies / dietary requirements/food preferences?

Yes:	What:
No:

Do you give consent for your child/children to be photographed or videotaped for media purposes (please tick):

Yes:
No: