CONSENT - Off-Site Activities Sept 2014 - Oct 2015

Lifted Youth is part of C4W Reg. Charity No.
1101305
Lifted Youth (Life Church), Bowles Wells Gardens, Kent, Ct19 6PQ
Tel: 01303-240033 Fax: 01303-240023

CONSENT FORM FOR PARTICIPANTS UNDER 18 YEARS
ON AN OFFSITE VISIT

Name of child: _____________________________ Date of birth: _____________

FOR ACTIVITIES PLANNED FOR LIFTED EVENTS FROM SEPTEMBER 2014 OCTOBER 2015
This consent form will cover all activities planned from September 2014 October 2015 that are off-
site. Activities are likely to include: train journey, ice-skating, bowling, tobogganing, swimming at a
water leisure park with wave machines and slides, park games, beachside BBQ, a bonfire/fireworks,
and shopping (not all activities are yet confirmed and may be subject to change).

A consent form for each child must be filled out and returned by a parent or adult with parental
responsibility for the child or they will not be able to attend the trips. Please contact us if there is a
change to anything on this form during the course of the year.

MEDICAL INFORMATION ABOUT YOUR SON / DAUGHTER / WARD

Name of GP: _____________________________________ Tel No: ____________________________

Address:
_________________________________________________________________________________

NHS No:________________________ Date of last anti-tetanus injection: ____________________________

My son/daughter/ward is in good physical health and I consider them fit to participate in general activities?
If NO, or if there are any exceptions you would like to specify, please give brief details: YES / NO

Do they have ANY conditions requiring medical treatment, including medication YES / NO
(e.g. asthma, epilepsy, diabetes etc.)? If YES please give brief details:

Do they have any conditions or disabilities which may affect undertaking an activity? YES / NO
If YES please give brief details:

Is your son/daughter/ward allergic to any medication / food / nuts / bee stings, etc? YES/ NO
If YES please give brief details:

SWIMMING ABILITY (answer all questions please)

Is your child able to swim 50 metres? YES / NO
Is your child confident in water? YES / NO
Is your child safety conscious in water? YES / NO

Lifted Youth is part of C4W Reg. Charity No. 1101305
Tel: 01303-240033 Fax: 01303-240023

TRAVEL
I give permission for my child(ren) to be transported (mini-bus, car, train) to and from activities as arranged
per activity, and in accordance with the Life Church Volunteer Driving Policy. Seat belts will be worn at all
times by all occupants of vehicles. Transport will be provided in vehicles that are fully roadworthy and with
drivers who have completed a DBS check.
YES / NO

PLEASE NOTE: DECLARATION BELOW MUST BE SIGNED BY PARENT/GUARDIAN

DECLARATION (BLOCK CAPS PLEASE)

I have read the above information and give permission for (full name of child/young person)
________________________________________________ to take part in the normal activities of
this group from September 2014 October 2015. I understand that separate permission will be
sought for certain activities and outings lasting longer than the normal meeting times of the group. I
understand that while involved he/she will be under the control and care of the group leader and/or
other adults approved by the leadership and that, while the staff in charge of the group will take all
reasonable care of the children, they cannot necessarily be held responsible for any loss, damage or
injury suffered by my child during, or as a result of, the activity.

Whenever medical advice or treatment is needed, the assistance of a GP or A&E Department of a
hospital should be sought. The Children Act 1989 allows a doctor to provide any necessary
treatment by doing what is reasonable in all the circumstances of the case for the purpose of
safeguarding or promoting the childs welfare.

However, the parent/carer should be contacted and advised of the situation as soon as possible. It is
important, however that those caring for children and young people on day trips, outings and
residential activities obtain in advance from the parent/carer:

1. All necessary information concerning the child/young persons health, allergies, medication
etc.
2. Written agreement as follows:

I understand:
My child will receive medication as instructed before or during the event.
Every effort will be made to contact me as soon as possible should my child become ill or have
an accident.
My child will be given medical/dental treatment as necessary.

Signed: ___________________________________________ Date: _______________________
(parent/or adult with parental responsibility)

Lifted Youth is part of C4W Reg. Charity No. 1101305
Tel: 01303-240033 Fax: 01303-240023

Parent/carer full name (please print):

Address:

Home Phone Number: Mobile Number:

Additional contact name (e.g. grandparent):

_____________________________________

Home Phone Number:_______________________________

Mobile Number: ____________________________________

Additional Consent:

Communicating with children & young people:
Children and young people communicate via telephone, mobile, email and the internet. Do you give
permission for children/youth workers to communicate via these methods to your child? E.g. contact via text
with changes to the youth meeting times.

I give permission for my child and the youth/childrens workers to communicate using telephone, mobile,
email, or internet for the purpose of arranging children/youth activities.
(Please delete forms of communication you dont want your child contacted by)

Images and videos:
To comply with the Data Protection Act 1998, permission must be granted by the parent/carer before any
images of your child/children are taken and used. Please answer questions 1 and 2 below, then sign and date
the form where shown.
1. May we use your child's image in our printed promotional publications? YES/NO
2. May we use your child's image on our website? YES/NO
We never include any details or names of children in photographs and will only include photos of youth
appropriately dressed (e.g. not photos from a swimming trip).

Signed: _______________________________________________ Date: _____________________
(parent/or adult with parental responsibility)

CONSENT - Off-Site Activities Sept 2014 - Oct 2015

Uploaded by

Copyright:

Available Formats

CONSENT - Off-Site Activities Sept 2014 - Oct 2015

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

CONSENT - Off-Site Activities Sept 2014 - Oct 2015

Uploaded by

Copyright:

Available Formats

Lifted Youth is part of C4W Reg. Charity No.

You might also like