Child 1

First Name

Last Name

Date of birth

MM

DD

YYYY

Child 2

First Name

Last Name

Date of birth

MM

DD

YYYY

Child 3

First Name

Last Name

Date of birth

MM

DD

YYYY

Child 4

First Name

Last Name

Date of birth

MM

DD

YYYY

FIRST PERSON TO CONTACT IN AN EMERGENCY (PARENT/CARER/GUARDIAN) *

First Name

Last Name

Phone number *

(###)

###

####

Mobile number

(###)

###

####

SECOND EMERGENCY CONTACT *

First Name

Last Name

Phone number *

(###)

###

####

Mobile number

(###)

###

####

Phone number *

(###)

###

####

Do any of your children suffer from allergies? *

Yes

No

Do any of your children have any medical conditions we should be aware of? *

Yes

No

Do any of your children have any disabilities we should be aware of? *

Yes

No

Are any of your children taking any medication? *

Yes

No

Please tick to acknowledge consent *

In an emergency and/or if I am not contactable I understand that my child(ren) will receive medical/dental treatment as necessary.

I give permission to the following

1) My child(ren) can take part in the normal activities of children’s and youth groups, which in addition to using the church building may include a trip to The Marl Park (small park near the church meeting place)

2) My child(ren) can participate in activities which may sometimes involve joining with another group from the church, or another church for a joint activity

3) My child(ren) can be transported (if needed) by using an approved leader’s car, and I understand that the drivers will adhere to Grace Church Child Safeguarding Policy – this will always be pre-arranged if needed

4) My child(ren) can have face paints used on their skin

5) My child(ren) can have a plaster applied if needed

6) My child(ren) can be taken to the toilet/have their nappy changed by a fully trained/DBS checked church volunteer if needed.

I agree to the following photograph permissions

1) The taking and use of photographs or video footage for presentations (e.g. drama, fun stuff) at kids/youth meetings or wider church meetings (e.g. showing church members what’s happening in the youth work)

2) The taking and use of photographs for the church instagram account (if requested, photographs can be shown before use on the church account)

3) Photographs or video footage for the church webpages (if requested, photographs can be shown before use on the church webpage)

Please tick to confirm *

I agree to advise the group leaders in writing if any of the above details change.

Date

MM

DD

YYYY