Peninsula Healthy Living Partnership

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nrg Registration 2010

Full Name of Child *

Child's Date of Birth: (only children aged 11-17 are eligible) *

Residential Address (incl. Postcode*) Participants must live in the BT22 area *

Parent/Carer’s Mobile Contact No:

Emergency Contact No:

Details of any known allergies, illnesses or health problems that you feel we should know about or may affect their participation in activities:

NB: We cannot administer any medication but we shall prompt your child to take his/her medication if required.

PARENTAL CONSENT/PERMISSION:

By submitting this consent form, I accept parental responsibility on behalf of my child that:

· All the information supplied is accurate and not misleading

· Any change in details will be advised to the designated Leader in Charge

· I consent to my child taking part in this programme and that any information that may affect my child’s ability to take part has been provided

· In the event that my child does not sign the attendance register I accept that the Leader in Charge is not responsible for their whereabouts

· If my child signs out and leaves the programme before it is over I will be contacted and I understand and accept that my child is no longer the responsibility of the Leader in Charge

· In the event of emergency that I shall respond promptly to deal with the matter

· If medical treatment is required that appropriate services may be contacted

· Peninsula Healthy Living may take photographs and video images and use these for promotional purposes in publications, websites, local press or promotional videos

· My child may use the e-C@fé under the supervision of the Leader in Charge and in compliance with the organisation’s policy on internet usage

· I agree to my child travelling with a member of staff or volunteer or being accompanied by them to activities that may be organised as part of the NRG programme

CONSENT OF YOUNG PERSON:

I confirm that I understand that by submitting this consent form that I agree to participate in this 9 week programme and that I shall comply with the attached Code of Conduct for participants which promotes good behaviour and respect and tolerance of others. I acknowledge that a breach of the rules may lead to my immediate dismissal.