Consent form

Name of Grassroot project your giving consent for

Young person's details

Full name *

Street Address *

Postcode *

Age *

Date of birth *

Gender

School *

Mobile phone number *

Parent or guardian details

Full name *

Relationship to young person *

Street AddressIf different from above

PostcodeIf different from above

Mobile phone number *

Home phone number

Email Address *

Emergency contact details

Emergency contact 1

Full name *

Relationship to young person *

Mobile phone number *

Home phone number

Emergency contact 2

Full name

Relationship to young person

Mobile phone number

Home phone number

Medical information

Any allergies, medical conditions or medication? *Fill in 'none is this is not applicable.

Any dietary requirements? *Fill in 'none is this is not applicable.

Do you need any facilities or support to enable you to take part in activities? *Fill in 'none is this is not applicable.

Any other things you think we need to know? *Fill in 'none is this is not applicable.

Declaration

Code of conduct *

I understand that while my child is participating on a Grassroot Communities club, programme, trip or residential they will be subject to the programmes general code of conduct. This includes following instructions that staff have given. Failure to do this could jeopardise your child’s place on this session and any future activities that Grassroot Communities run.

Loss or damage *

I understand Grassroot Communities cannot be held responsible for any loss or damage to my child’s personal possessions.

Share information with other youth agencies *

I give my consent for Grassroot Communities to share information regarding my child with other youth agencies and funders for monitoring purposes.

Images and videos consent

Images and videos *

I'm happy that photos/videos and other images of my child may be used for marketing purposes, promoting Grassroot Communities through our social media pages/ website and public promotion of Grassroot Communities.